Accreditation Report - Shriners Hospitals for Children

Transcription

Accreditation Report
Shriners Hospital for Children (Québec) Inc.
Montréal, QC
On-site survey dates: June 2, 2013 - June 6, 2013
Report issued: June 20, 2013
Accredited by ISQua
QMENTUM PROGRAM
About the Accreditation Report
Shriners Hospital for Children (Québec) Inc. (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 June 2013. Information from the on-site survey as well as other data obtained
from the organization were used to produce this Accreditation Report.
Accreditation results are based on information provided by the organization. Accreditation Canada relies on the
accuracy of this information to plan and conduct the on-site survey and produce the Accreditation 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 Accreditation Report to staff, board members, clients, the community, and other stakeholders.
Any alteration of this Accreditation Report compromises the integrity of the accreditation process and is strictly
prohibited.
© Accreditation Canada, 2013
QMENTUM PROGRAM
A Message from Accreditation Canada's President and CEO
On behalf of Accreditation Canada's board and staff, I extend my sincerest congratulations to your board, your
leadership team, and everyone at your organization on your participation in the Qmentum accreditation program.
Qmentum is designed to integrate with your quality improvement program. By using Qmentum to support and
enable your quality improvement activities, its full value is realized.
This Accreditation Report includes your accreditation decision, the final results from your recent on-site survey,
and the instrument data that your organization has submitted. Please use the information in this report and in
your online Quality Performance Roadmap to guide your quality improvement activities.
Your Accreditation Specialist is available if you have questions or need guidance.
Thank you for your leadership and for demonstrating your ongoing commitment to quality by integrating
accreditation into your improvement program. We welcome your feedback about how we can continue to
strengthen the program to ensure it remains relevant to you and your services.
We look forward to our continued partnership.
Sincerely,
Wendy Nicklin
President and Chief Executive Officer
A Message from Accreditation Canada's President and CEO
QMENTUM PROGRAM
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
4
1.4 Overview by Standards
5
1.5 Overview by Required Organizational Practices
7
1.6 Summary of Surveyor Team Observations
12
2.0 Detailed Required Organizational Practices Results
13
3.0 Detailed On-site Survey Results
14
3.1 Priority Process Results for System-wide Standards
15
3.1.1 Priority Process: Planning and Service Design
15
3.1.2 Priority Process: Governance
16
3.1.3 Priority Process: Resource Management
17
3.1.4 Priority Process: Human Capital
18
3.1.5 Priority Process: Integrated Quality Management
19
3.1.6 Priority Process: Principle-based Care and Decision Making
20
3.1.7 Priority Process: Communication
21
3.1.8 Priority Process: Physical Environment
22
3.1.9 Priority Process: Emergency Preparedness
23
3.1.10 Priority Process: Patient Flow
24
3.1.11 Priority Process: Medical Devices and Equipment
25
3.2 Service Excellence Standards Results
26
3.2.1 Standards Set: Ambulatory Care Services
27
3.2.2 Standards Set: Biomedical Laboratory Services
29
3.2.3 Standards Set: Blood Bank and Transfusion Services
30
3.2.4 Standards Set: Diagnostic Imaging Services
31
3.2.5 Standards Set: Infection Prevention and Control
33
3.2.6 Standards Set: Laboratory and Blood Services
34
3.2.7 Standards Set: Managing Medications
35
3.2.8 Standards Set: Point-of-Care Testing
36
3.2.9 Standards Set: Rehabilitation Services
37
3.2.10 Standards Set: Telehealth Services
39
Table of Contents
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3.2.11 Priority Process: Surgical Procedures
4.0 Instrument Results
41
43
4.1 Governance Functioning Tool
43
4.2 Patient Safety Culture Tool
47
4.3 Worklife Pulse Tool
49
4.4 Client Experience Tool
51
Appendix A Qmentum
52
Appendix B Priority Processes
53
Table of Contents
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QMENTUM PROGRAM
Section 1
Executive Summary
Shriners Hospital for Children (Québec) Inc. (referred to in this report as “the organization”) is participating in
Accreditation Canada's Qmentum accreditation program. Accreditation Canada is an independent, not-for-profit
organization that sets standards for quality and safety in health care and accredits health organizations in Canada
and around the world.
As part of the Qmentum accreditation program, the organization has undergone a rigorous evaluation process.
Following a comprehensive self-assessment, external peer surveyors conducted an on-site survey during which
they assessed this organization's leadership, governance, clinical programs and services against Accreditation
Canada requirements for quality and safety. These requirements include national standards of excellence;
required safety practices to reduce potential harm; and questionnaires to assess the work environment, patient
safety culture, governance functioning and client experience. Results from all of these components are included
in this report and were considered in the accreditation decision.
This report shows the results to date and is provided to guide the organization as it continues to incorporate the
principles of accreditation and quality improvement into its programs, policies, and practices.
The organization is commended on its commitment to using accreditation to improve the quality and safety of the
services it offers to its clients and its community.
1.1 Accreditation Decision
Shriners Hospital for Children (Québec) Inc.'s accreditation decision is:
Accredited with Commendation (Report)
The organization has surpassed the fundamental requirements of the accreditation program.
Executive Summary
1
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1.2 About the On-site Survey
• On-site survey dates: June 2, 2013 to June 6, 2013
• Locations
The following locations were assessed during the on-site survey. All sites and services offered by the
organization are deemed accredited.
1
2
Shriners Hospital for Children (Quebec) Inc.
Shriners Hospital for Children (Québec) Inc. - Botox Clinic - Queen Elizabeth Health Complex
• Standards
The following sets of standards were used to assess the organization's programs and services during the
on-site survey.
System-Wide Standards
1
Leadership
2
Governance
Service Excellence Standards
3
Managing Medications
4
Operating Rooms
5
Reprocessing and Sterilization of Reusable Medical Devices
6
Surgical Care Services
7
Point-of-Care Testing
8
Infection Prevention and Control
9
Ambulatory Care Services
10
Biomedical Laboratory Services
11
Diagnostic Imaging Services
12
Laboratory and Blood Services
13
Rehabilitation Services
14
Blood Bank and Transfusion Services
15
Telehealth Services
Executive Summary
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QMENTUM PROGRAM
• Instruments
The organization administer:
1
Governance Functioning Tool
2
Patient Safety Culture Tool
3
Worklife Pulse Tool
4
Client Experience Tool
Executive Summary
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1.3 Overview by Quality Dimensions
Accreditation Canada defines quality in health care using eight dimensions that represent key service elements.
Each criterion in the standards is associated with a quality dimension. This table shows the number of criteria
related to each dimension that were rated as met, unmet, or not applicable.
Quality Dimension
Met
Unmet
N/A
Total
Population Focus (Working with communities to
anticipate and meet needs)
39
2
1
42
Accessibility (Providing timely and equitable
services)
58
1
6
65
415
14
49
478
Worklife (Supporting wellness in the work
environment)
98
1
4
103
Client-centred Services (Putting clients and
families first)
83
4
4
91
Continuity of Services (Experiencing coordinated
and seamless services)
27
0
2
29
Effectiveness (Doing the right thing to achieve the
best possible results)
622
17
33
672
60
1
0
61
1402
40
99
1541
Safety (Keeping people safe)
Efficiency (Making the best use of resources)
Total
Executive Summary
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1.4 Overview by Standards
The Qmentum standards identify policies and practices that contribute to high quality, safe, and effectively
managed care. Each standard has associated criteria that are used to measure the organization's compliance with
the standard.
System-wide standards address quality and safety at the organizational level in areas such as governance and
leadership. Population-specific and service excellence standards address specific populations, sectors, and
services. The standards used to assess an organization's programs are based on the type of services it provides.
This table shows the sets of standards used to evaluate the organization's programs and services, and the number
and percentage of criteria that were rated met, unmet, or not applicable during the on-site survey.
Accreditation decisions are based on compliance with standards. Percent compliance is calculated to the decimal
and not rounded.
High Priority Criteria *
Total Criteria
(High Priority + Other)
Other Criteria
Met
Unmet
N/A
Met
Unmet
N/A
Met
Unmet
N/A
# (%)
# (%)
#
# (%)
# (%)
#
# (%)
# (%)
#
Governance
44
(100.0%)
0
(0.0%)
0
33
(97.1%)
1
(2.9%)
0
77
(98.7%)
1
(1.3%)
0
Leadership
45
(100.0%)
0
(0.0%)
1
81
(97.6%)
2
(2.4%)
2
126
(98.4%)
2
(1.6%)
3
Diagnostic Imaging
Services
55
(94.8%)
3
(5.2%)
9
47
(88.7%)
6
(11.3%)
8
102
(91.9%)
9
(8.1%)
17
Infection Prevention
and Control
38
(95.0%)
2
(5.0%)
3
37
(97.4%)
1
(2.6%)
2
75
(96.2%)
3
(3.8%)
5
Ambulatory Care
Services
30
(96.8%)
1
(3.2%)
7
69
(98.6%)
1
(1.4%)
5
99
(98.0%)
2
(2.0%)
12
Biomedical Laboratory
Services
16
(100.0%)
0
(0.0%)
0
36
(100.0%)
0
(0.0%)
0
52
(100.0%)
0
(0.0%)
0
Blood Bank and
Transfusion Services
27
(100.0%)
0
(0.0%)
15
15
(100.0%)
0
(0.0%)
2
42
(100.0%)
0
(0.0%)
17
Laboratory and Blood
Services
79
(98.8%)
1
(1.3%)
1
93
(98.9%)
1
(1.1%)
1
172
(98.9%)
2
(1.1%)
2
Managing Medications
53
(93.0%)
4
(7.0%)
19
35
(94.6%)
2
(5.4%)
15
88
(93.6%)
6
(6.4%)
34
Operating Rooms
68
(100.0%)
0
(0.0%)
1
29
(96.7%)
1
(3.3%)
0
97
(99.0%)
1
(1.0%)
1
Standards Set
Executive Summary
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High Priority Criteria *
Total Criteria
(High Priority + Other)
Other Criteria
Met
Unmet
N/A
Met
Unmet
N/A
Met
Unmet
N/A
# (%)
# (%)
#
# (%)
# (%)
#
# (%)
# (%)
#
Point-of-Care Testing
38
(100.0%)
0
(0.0%)
0
47
(100.0%)
0
(0.0%)
1
85
(100.0%)
0
(0.0%)
1
Rehabilitation Services
26
(96.3%)
1
(3.7%)
0
64
(95.5%)
3
(4.5%)
1
90
(95.7%)
4
(4.3%)
1
Reprocessing and
Sterilization of
Reusable Medical
Devices
37
(97.4%)
1
(2.6%)
2
55
(96.5%)
2
(3.5%)
2
92
(96.8%)
3
(3.2%)
4
Surgical Care Services
29
(96.7%)
1
(3.3%)
0
63
(96.9%)
2
(3.1%)
0
92
(96.8%)
3
(3.2%)
0
Telehealth Services
30
(100.0%)
0
(0.0%)
0
36
(97.3%)
1
(2.7%)
0
66
(98.5%)
1
(1.5%)
0
Total
615
(97.8%)
14
(2.2%)
58
740
(97.0%)
23
(3.0%)
39
1355
(97.3%)
Standards Set
37
(2.7%)
97
* Does not includes ROP (Required Organizational Practices)
Executive Summary
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1.5 Overview by Required Organizational Practices
A Required Organizational Practice (ROP) is an essential practice that an organization must have in place to
enhance client safety and minimize risk. Each ROP has associated tests for compliance, categorized as major and
minor. All tests for compliance must be met for the ROP as a whole to be rated as met.
This table shows the ratings of the applicable ROPs.
Required Organizational Practice
Overall rating
Test for Compliance Rating
Major Met
Minor Met
Patient Safety Goal Area: Safety Culture
Adverse Events Disclosure
(Leadership)
Met
3 of 3
0 of 0
Adverse Events Reporting
(Leadership)
Met
1 of 1
1 of 1
Client Safety Quarterly Reports
(Leadership)
Met
1 of 1
2 of 2
Client Safety Related Prospective Analysis
(Leadership)
Met
1 of 1
1 of 1
Client And Family Role In Safety
(Ambulatory Care Services)
Met
2 of 2
0 of 0
(Diagnostic Imaging Services)
Met
2 of 2
0 of 0
(Rehabilitation Services)
Met
2 of 2
0 of 0
(Surgical Care Services)
Met
2 of 2
0 of 0
Dangerous Abbreviations
(Managing Medications)
Met
4 of 4
3 of 3
Information Transfer
Met
2 of 2
0 of 0
Patient Safety Goal Area: Communication
Executive Summary
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Overall rating
Major Met
Minor Met
Met
2 of 2
0 of 0
Met
2 of 2
0 of 0
Medication Reconciliation As An
Organizational Priority
(Leadership)
Met
4 of 4
0 of 0
Medication Reconciliation At Admission
Met
5 of 5
2 of 2
Unmet
3 of 4
1 of 1
Unmet
3 of 4
1 of 1
Medication Reconciliation at Transfer or
Discharge
Met
4 of 4
1 of 1
Discharge
Met
4 of 4
1 of 1
Discharge
Met
4 of 4
1 of 1
Surgical Checklist
(Operating Rooms)
Met
3 of 3
2 of 2
Two Client Identifiers
Met
1 of 1
0 of 0
Met
1 of 1
0 of 0
Met
1 of 1
0 of 0
Executive Summary
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Overall rating
Major Met
Minor Met
(Operating Rooms)
Met
1 of 1
0 of 0
(Point-of-Care Testing)
Met
1 of 1
0 of 0
Met
1 of 1
0 of 0
Met
1 of 1
0 of 0
Concentrated Electrolytes
Met
1 of 1
0 of 0
Heparin Safety
Met
4 of 4
0 of 0
Infusion Pumps Training
Met
1 of 1
0 of 0
Met
1 of 1
0 of 0
(Operating Rooms)
Met
1 of 1
0 of 0
Met
1 of 1
0 of 0
Met
1 of 1
0 of 0
Medication Concentrations
Met
1 of 1
0 of 0
Narcotics Safety
Met
3 of 3
0 of 0
Patient Safety Goal Area: Medication Use
Executive Summary
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Overall rating
Major Met
Minor Met
Patient Safety Goal Area: Worklife/Workforce
Client Safety Plan
(Leadership)
Met
2 of 2
2 of 2
Client Safety: Education And Training
(Leadership)
Met
1 of 1
0 of 0
Preventive Maintenance Program
(Leadership)
Met
3 of 3
1 of 1
Workplace Violence Prevention
(Leadership)
Met
5 of 5
3 of 3
Met
1 of 1
2 of 2
Unmet
1 of 2
0 of 0
Infection Rates
(Infection Prevention and Control)
Met
1 of 1
3 of 3
Sterilization Processes
Met
1 of 1
1 of 1
Falls Prevention Strategy
Met
3 of 3
2 of 2
Met
3 of 3
2 of 2
Met
3 of 3
2 of 2
Met
3 of 3
2 of 2
Met
3 of 3
2 of 2
Patient Safety Goal Area: Infection Control
Hand Hygiene Audit
Hand Hygiene Education And Training
Patient Safety Goal Area: Falls Prevention
Patient Safety Goal Area: Risk Assessment
Pressure Ulcer Prevention
Executive Summary
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Overall rating
Major Met
Minor Met
3 of 3
2 of 2
Patient Safety Goal Area: Risk Assessment
Pressure Ulcer Prevention
Met
Executive Summary
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1.6 Summary of Surveyor Team Observations
The surveyor team made the following observations about the organization's overall strengths,
opportunities for improvement, and challenges.
The Shriners children’s hospital provides compassionate, family centered and specialized care to children
requiring specialized care from across North America. The hospital should be very proud of their success and
commitment to safe, quality care.
The board has broad, dedicated, and knowledgeable representation. There is representation from across the
country. The depth of the Shriners organization allows for the provision of strong leadership to the organization.
This has served the hospital well. The board may wish to consider a process to receive formal feedback from the
families regarding the services provided.
The community partners highlighted the multiple strong relationships the organization fosters in the community.
While focusing on its core competence of providing specialized service, the organization has developed effective
partnerships to cover other essential services. These include pharmacy, laboratory services and the medical and
surgical services with the other children's hospitals services. The collaborative approach ensures excellent
continuity of care and a seamless experience for the patient.
The collaborative leadership style at Shriner's is evident and contributes to a calm and smooth care
environment. Leaders promote and support learning environment evidence by the high level of program
collaboration and professional development available for staff. The leadership team has a commitment to
quality and safe care. The leadership team is encouraged to prepare for the transition to the new building and
may wish to consider leadership development in the areas of transformational change and resiliency. Any
changes and new processes that can be implemented in advance of the move are suggested. Considerable work
must be put forth to transition to the new building and enhanced partnerships with the other hospital.
The organization enjoys long term staff commitment with low turnover and high levels of morale. The leadership
team is encouraged to continue to foster an open and transparent dialogue to ensure a just culture.
The delivery of care and services revolve around the needs of the children as they present. There is an authentic
patient and family centered approach to all care and services provided. The commitment to providing research
informed, excellent clinical care is obvious.
Despite working in an aging environment the leadership team is encouraged to remember they are providing life
memories to their patients and their families and should not allow the physical environment to be a barrier to
providing an excellent patient care experience. The new building project presents a unique opportunity for the
organization to review their processes and to be prepared to move into a much larger space, working much
closer to a large academic pediatric organization. Success will contribute to high levels of employee retention
and the known reputation of a highly functioning and performing organization providing excellent specialized
care for children.
Overall, the patients and their families are very satisfied with the service provision at Shriners. The families
easily express gratitude; they love the hospital and often describe it as having a family feel to it.
Executive Summary
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Section 2
Detailed Required Organizational Practices Results
Each ROP is associated with one of the following patient safety goal areas: safety culture, communication,
medication use, worklife/workforce, infection control, or risk assessment.
This table shows each unmet ROP, the associated patient safety goal, and the set of standards where it appears.
Standards Set
Unmet Required Organizational Practice
The team reconciles the client's medications upon
admission to the organization, with the involvement of the
client, family or caregiver.
· Surgical Care Services 7.13
· Rehabilitation Services 7.4
Patient Safety Goal Area: Infection Control
Hand Hygiene Education And Training
The organization delivers hand-hygiene education and
training for staff, service providers, and volunteers.
· Infection Prevention and Control 6.1
Detailed Required Organizational Practices Results
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Section 3
Detailed On-site Survey Results
This section provides the detailed results of the on-site survey. When reviewing these results, it is important to
review the service excellence and the system-wide results together, as they are complementary. Results are
presented in two ways: first by priority process and then by standards sets.
Accreditation Canada defines priority processes as critical areas and systems that have a significant impact on the
quality and safety of care and services. Priority processes provide a different perspective from that offered by
the standards, organizing the results into themes that cut across departments, services, and teams.
For instance, the patient flow priority process includes criteria from a number of sets of standards that address
various aspects of patient flow, from preventing infections to providing timely diagnostic or surgical services. This
provides a comprehensive picture of how patients move through the organization and how services are delivered
to them, regardless of the department they are in or the specific services they receive.
During the on-site survey, surveyors rate compliance with the criteria, provide a rationale for their rating, and
comment on each priority process.
Priority process comments are shown in this report. The rationale for unmet criteria can be found in the
organization's online Quality Performance Roadmap.
See Appendix B for a list of priority processes.
INTERPRETING THE TABLES IN THIS SECTION: The tables show all unmet criteria from each set of
standards, identify high priority criteria (which include ROPs), and list surveyor comments related to
each priority process.
High priority criteria and ROP tests for compliance are identified by the following symbols:
High priority criterion
ROP
MAJOR
Major ROP Test for Compliance
MINOR
Minor ROP Test for Compliance
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3.1 Priority Process Results for System-wide Standards
The results in this section are presented first by priority process and then by standards set.
Some priority processes in this section also apply to the service excellence standards. Results of unmet criteria
that also relate to services should be shared with the relevant team.
3.1.1 Priority Process: Planning and Service Design
Developing and implementing infrastructure, programs, and services to meet the needs of the populations and
communities served
Unmet Criteria
High Priority
Criteria
Standards Set: Leadership
5.3
The organization's information about the community is maintained in a
format that is up-to-date and easy to understand.
Surveyor comments on the priority process(es)
Senior administration is proactive in updating the vision and operational plan of the hospital. They started
the process before the Head office in Tampa. This allowed them to be better prepared. There is a strong
alignment between mission, vision and the operation of the hospital. All decisions are anchored in the
mission and vision of the hospital. The staff is clearly aware of the mission and the vision of the hospital.
The Shriner's board structure does not have user group representation. Even if the board has informal
methods to connect with families and they have an excellent patient feedback surveys, the board could
benefit from formalizing how to get family involved in the planning of services.
The hospital has created strong partnerships with community partners to enable them to support their vision
while supporting their partners' needs resulting in symbiotic relationship. The hospital has designed clinical
programs in collaboration with community partners to complement local, provincial and national services,
thus avoiding duplication of services. This has allowed the hospital to provide highly specialized clinical
program.
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3.1.2 Priority Process: Governance
Meeting the demands for excellence in governance practice.
Unmet Criteria
High Priority
Criteria
Standards Set: Governance
13.9
The governing body prepares an annual report of its achievements.
The dedication of board members is noticeable. They show a strong commitment to patients and their
organization.
The board benefits from the guidance and wisdom of the organization in Tampa. The structure provided by
the organization allows them to operate effectively. The composition of the board is planned and carefully
selected to ensure the functioning of the hospital.
Board members appeared to have a strong presence within the hospital while not interfering with the internal
operations, allowing the administrator to do her job.
The board has clear understanding of their mission. They are able to find a niche within the Shriner system
and the local and provincial health care system.
The board supports a culture of professional development for staff and physicians. They confirm their
commitment by the resources allocated to these activities.
The board could benefit from getting more formal feedback for the patients they serve. The board is
encouraged to explore means to obtain this feedback. The family advisory committee can be used a resource
to the board to obtain feedback.
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3.1.3 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.
The hospital has strong and structured financial reporting system in place. The fact that they have to
generate two financial reports, one to the province and one for the Shriner allows them to have strong bookkeeping procedures.
The hospital is operation within their allocated budget.
The allocation of contracts is shared amongst few departments. Centralizing the process under one portfolio
could assist in ensuring consistency.
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3.1.4 Priority Process: Human Capital
Developing the human resource capacity to deliver safe, high quality services
The hospital has a very supportive professional development plan allowing staff to continuously improve their
knowledge and skills.
The violence prevention in the workplace policy has been recently updated. Human resources have
coordinated a staff awareness program on how to deescalate tense situation using scenario based approach.
Human resources have put in place a detailed strong human resources plan taking into consideration staff
eligible for retirement, maternity leave and new clinical requirement based on clinical program expansion.
The plan will serve as the backbone of resources allocation from Shriner headquarters for the implementation
of new services at the new site.
Performance appraisals have been renamed to "appreciation des competences". Human Resources lead an
educational campaign to promote the positive use of their new tool. All managers have got their
performance appraisal done since November 2012. The percentage of performance appraisal went from 7% to
25% to date. The hospital is encouraged to continue their commitment to have performance appraisal done
regularly.
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3.1.5 Priority Process: Integrated Quality Management
Using a proactive, systematic, and ongoing process to manage and integrate quality and achieve organizational
goals and objectives
The organization has a well-documented safety plan and is seen by the accreditation coordinator to meet the
needs of a quality framework and integrated risk management plan. There is attention to safety and quality
here and it is suggested the organization to formalize the process around risk and quality.
Like in many organizations, the patient safety culture tool was completed however it has many red flags that
relate to a culture of fearfulness and a reluctance to speak up. It has been sated this has been an ongoing
challenge and the organization is encouraged to formally address this with staff to ensure a "just" culture.
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3.1.6 Priority Process: Principle-based Care and Decision Making
Identifying and decision making regarding ethical dilemmas and problems.
The Ethical Decision making guide is specific only for clinical care and research is separated out. Institutional
review board of faculty of medicine oversees research ethics.
There is ongoing work to look at professional boundaries as it relates to the use of social media and the need
for standards.
The ethics committee has deliberate turnover to saturate staff learning which is seen as a good strategy. The
committee is encouraged to continue to examine and seek to resolve the concern for process for Do Not
Resuscitate (DNR) patients and patient with previous limited resuscitation status.
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3.1.7 Priority Process: Communication
Communicating effectively at all levels of the organization and with external stakeholders
During the survey, we realized that there are very strong links between the Shriner’s international
organization, the community and the hospital for communication service.
There is a large variety of documentation, publications and other activities promoting the hospital and the
quality of services. The documents are distributed largely to the staff, the community, the partners, Shriners’
donators, etc. and they are very well done allowing attracting by all audiences.
They also participate largely on the consultation tables with partners and community; they inform partners
and population of research results and discoveries, new practices, etc. They organize a lot of fund raising
with the Shriners.
They have a lot of projects to promote fund raising, and hospital realization through intranet, internet, social
media, television, etc. They also are working on getting the 2013 annual report more attractive.
One of the communication challenges is to cope with the effects of going in a new and larger hospital.
21
QMENTUM PROGRAM
3.1.8 Priority Process: Physical Environment
Providing appropriate and safe structures and facilities to achieve the organization's mission, vision, and goals
We must insist on the cleanness of corridors, units, stairs, garage, maintenance and circulation paths are to
be commended. We encourage the organization to pay attention to certain posters and other documents put
on walls, some of them seem old and have visible splatter and dirt on them.
There are many boxes piled around the desks in the sector of the research. It seems that this situation is
known and connected with the lack of space and that should be solved at the time of the moving in the new
hospital.
Many positive comments about the quality of foods were mentioned. Patients and family express their
satisfaction about cleanness of hospital and units, food and the exterior environment.
The housekeeping chief participates in the prevention and control of infection meetings and is aware of the
importance of rigor. If construction is made in the hospital, the norms are known and the responsible of
prevention of infection is implicated.
They have a preoccupation for green solutions and recycling. They apply preventive solutions to avoid
contamination, for example, the half wall preventing an accidental oil spillage.
There were a lot of updates done in last years on the emergency plan, including new codes, a friendly user
flipchart, exercises, etc. We encourage the organization to maintain efforts to keep everybody alert with
emergency plan and activities.
22
QMENTUM PROGRAM
3.1.9 Priority Process: Emergency Preparedness
Planning for and managing emergencies, disasters, or other aspects of public safety
Unmet Criteria
High Priority
Criteria
Standards Set: Leadership
14.8
The organization's leaders develop and implement an emergency
communication plan.
There were a lot of updates done in last years on the emergency plan, including new codes for example for
and active shooter, a friendly user flipchart, table and real exercises, adequate and precise signage, etc. It
is also interesting that the garage was dedicated as an assembling point in case of disaster, by this situation
out of the hospital. The organization is encouraged to maintain efforts to keep everybody alert with
emergency plan and activities.
There is a communication plan for crisis situation which is a general one. The organization is encouraged to
develop one based on the local organization.
Anterior exercises have been performed like Arc-en-ciel and Cameleon, which provided the organization with
a lot of information about the challenges of a disaster and helped to cope with. The organization is
encouraged to maintain this expertise and to also do spot checks to develop emergency reflex.
There is a formation about reaction to violent persons notably Omega type which is planned for next
September.
The organization organized a fire brigade to have a more specialized staff in case of fire. Their formation is
reviewed each 2 years. There will be a challenge to upgrade emergency plan and formation for the new
hospital.
The organization has done prospective analysis on white and yellow codes, with simulation and table
exercises. There exist coordination plans with partners in case of disaster
23
QMENTUM PROGRAM
3.1.10 Priority Process: Patient Flow
Assessing the smooth and timely movement of clients and families through service settings
The hospital has revamped their triage process to better manage waiting list. They keep track of specific
performance indicators to allow to effectively monitoring patient flow. All indicators were within target.
24
QMENTUM PROGRAM
3.1.11 Priority Process: Medical Devices and Equipment
Obtaining and maintaining machinery and technologies used to diagnose and treat health problems
Unmet Criteria
High Priority
Criteria
Standards Set: Reprocessing and Sterilization of Reusable Medical Devices
2.4
Supervisors and staff members involved in reprocessing have completed a
recognized course in reprocessing and sterilization.
5.1
The medical device reprocessing department is equipped with hand hygiene
facilities at entrances to and exits from the reprocessing areas, including
personnel support areas.
5.2
The medical device reprocessing department's hand hygiene facilities are
equipped with faucets supplied with foot-, wrist-, or knee-operated
handles, or electric eye controls.
The sterile processing area is exceedingly organized, absent of visual clutter and has engaged leadership and
team. The Senergy System for Preventative maintenance and tracking is effective and well maintained. The
hospital staff works closely with the Montreal Children's when purchasing equipment to ensure
standardization between the two organizations.
The leader of the area does not have current education in reprocessing. It is suggested to put a hand hygiene
station or a dispenser at the entrance to the reprocessing area. The sinks in the decontamination area do not
have foot or wrist or knee operated handles. Older facility and issue will be addressed with move.
25
QMENTUM PROGRAM
3.2 Service Excellence Standards Results
The results in this section are grouped first by standards set and then by priority process.
Priority processes specific to service excellence standards are:
Point-of-care Testing Services
Using non-laboratory tests delivered at the point of care to determine the presence of health problems
Clinical Leadership
Providing leadership and overall goals and direction to the team of people providing services.
Competency
Developing a skilled, knowledgeable, interdisciplinary team that can manage and deliver effective programs
and services
Episode of Care
Providing clients with coordinated services from their first encounter with a health care provider through
their last contact related to their health issue
Decision Support
Using information, research, data, and technology to support management and clinical decision making
Impact on Outcomes
Identifying and monitoring process and outcome measures to evaluate and improve service quality and client
outcomes
Medication Management
Using interdisciplinary teams to manage the provision of medication to clients
Infection Prevention and Control
Implementing measures to prevent and reduce the acquisition and transmission of infection among staff,
service providers, clients, and families
Surgical Procedures
Delivering safe surgical care, including preoperative preparation, operating room procedures, postoperative
recovery, and discharge
Diagnostic Services: Imaging
Ensuring the availability of diagnostic imaging services to assist medical professionals in diagnosing and
monitoring health conditions
Diagnostic Services: Laboratory
Ensuring the availability of laboratory services to assist medical professionals in diagnosing and monitoring
health conditions
26
QMENTUM PROGRAM
Blood Services
Handling blood and blood components safely, including donor selection, blood collection, and transfusions
3.2.1 Standards Set: Ambulatory Care Services
Unmet Criteria
High Priority
Criteria
Priority Process: Clinical Leadership
Priority Process: Competency
4.9
Team leaders regularly evaluate and document each team member's
performance in an objective, interactive, and positive way.
Priority Process: Episode of Care
Priority Process: Decision Support
Priority Process: Impact on Outcomes
17.3
Staff and service providers participate in regular safety briefings to share
information about potential safety problems, reduce the risk of error, and
improve the quality of service.
There is a group of staff members who is very engaged and very attentive to the needs of the children and
their families. Leader conveys an open and calm approach which appears to be reflective in the staff.
The infonurse line is an exceptional way to be available to patients and their families.
Pump education is provided at orientation and if a staff requests it. It would be beneficial to have a regular
process in place to ensure regular reviews. There are only twenty pumps in the building and used only in one
area which would make this process easily implemented.
Evidence of a formal and regular process for performance, feedback or appraisals was not found in
ambulatory care. When asked some staff could not articulate when they last had an appraisal. An
improvement from 7% to 25% in compliance is noted.
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QMENTUM PROGRAM
The leader has addressed the concerns regarding wait times and is engaged in ongoing quality improvement
to assess the wait times for patients and their families once they arrive to the clinic.
Quality work going on to look at the wait time once arrived at clinic.
Medication reconciliation is noted as a met criteria as demonstrated in pre-Admission. This indicator is not
appropriate for the formal ambulatory care process. Ambulatory care does meet the requirements for
medication reconciliation at interface care in Ambulatory care although the need for it in the clinic is
infrequent.
No comments
There are no formal safety walk rounds. Annual mock up room of patient safety issues takes place and is
recalled by staff.
There is good attention to safety and it is suggested to formalize and put a process around what is taking
place.
There is evidence of a strong approach to the prevention of falls. The ambulatory waiting space would be a
great place to post these.
28
QMENTUM PROGRAM
3.2.2 Standards Set: Biomedical Laboratory Services
Unmet Criteria
High Priority
Criteria
Priority Process: Diagnostic Services: Laboratory
The Laboratory staff is a highly motivated professional team that strives to achieve the needs and
expectations of their laboratory users and patients. Laboratory leadership and staff have developed an
excellent rapport with nursing and medical staff. Contracted laboratory services are essential to the
organization to provide patient care services. The resource person at each site is an asset to the continuity
and quality of service.
Laboratory services provide nursing with a complete user friendly primary sample collection manual as a
resource tool for sample collections. All other lab related policies and procedures are posted on the intranet.
The Lab continues to provide ongoing training and competency monitoring to assist the lab users with the
pre-analytical process and ensure quality outcomes.
The Laboratory has a quality assurance program in place and it being followed. Leadership team review and
monitor quality indicators and trends to improve future services.
Laboratory results are received from contracted services and the on-site laboratory. These results are placed
on the patient chart and are not entered in the SHCIS electronic system. Contracted services provides
microbiology testing excluding weekend resulting , although these results can be release as requested.
29
QMENTUM PROGRAM
3.2.3 Standards Set: Blood Bank and Transfusion Services
Unmet Criteria
High Priority
Criteria
Priority Process: Blood Services
Priority Process: Blood Services
The multi- discipline transfusion committee has developed, trained and implemented the use of a new
informed consent form for patient care, along with information outlining their options and risk factors. The
nursing staff is aware of and trained on policies, procedure and risks of administration of blood and blood
products.
The organization is encouraged to expand the multi -discipline committee to include: physician or medical
director.
30
QMENTUM PROGRAM
3.2.4 Standards Set: Diagnostic Imaging Services
Unmet Criteria
High Priority
Criteria
Priority Process: Diagnostic Services: Imaging
1.2
The team collects information at least annually from referring medical
professionals about their needs for diagnostic imaging services.
1.3
The team meets at least annually to review information collected from
clients and medical professionals to identify strengths and areas for
improvement in service needs, and make changes accordingly.
4.5
The client service area is equipped with a private and secure space for
clients to change.
4.10
The team posts safety warnings at the entrance of the imaging room and
restricts access when it is in use.
6.7
The team annually reviews and updates the Policy and Procedure Manual.
17.3
The team collects, analyzes, and interprets data on the appropriateness of
examinations, the accuracy of the interpretations, and the incidence of
complications and adverse events.
17.4
The team reviews its diagnostic reference levels at least annually as part of
its quality improvement program.
17.6
The team uses a utilization management or review process to monitor
diagnostic imaging services.
17.7
The team uses results of the utilization management review to educate
referring medical professionals and diagnostic imaging providers on the
appropriate use of diagnostic imaging services.
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QMENTUM PROGRAM
Priority Process: Diagnostic Services: Imaging
Diagnostic imaging is a small service within the hospital. Three radiologists provide service. One of these
physicians is highly specialized, two provide ultrasound interpretation. All are on the medical staff of other
facilities. There are a number of activities that need to be incorporated into the annual work plan of the
department. These include utilization management, review of diagnostic reference levels, policy review and
review of areas for improvement.
No evidence of peer review were found within the Shriners Hospital itself. This does not mean that such
review does not take place in the other institutions that these physicians serve, but there does not appear to
be a link back to the hospital.
The overall impression of the service was of a highly competent and dedicated group of individuals with high
morale. The physician leader was not on site but was willing to speak by telephone from Central Europe.
32
QMENTUM PROGRAM
3.2.5 Standards Set: Infection Prevention and Control
Unmet Criteria
High Priority
Criteria
Priority Process: Infection Prevention and Control
5.4
Staff, service providers, and volunteers attend the IPAC education program
at orientation and regularly thereafter.
6.1
The organization delivers hand-hygiene education and training for staff,
service providers, and volunteers.
6.1.1
Education and training on hand hygiene and the hand-hygiene
protocol is delivered.
10.2
The organization properly cleans and disinfects client and staff areas.
11.6
The organization uses safety engineered devices for sharps and other
high-risk materials.
ROP
MAJOR
Priority Process: Infection Prevention and Control
The infection prevention and control (IPAC) practitioner has a 0.6 FTE position. She is passionate about her
work and is proud of the hospital's accomplishments in protecting patients and staff from infection. Given the
nature of the clinical work and the way it is done, there have been very few post-operative infections. From
a high of 2.4% in 1994, 30 day post-operative infection rates have fallen to well below 0.5% since 2005. This is
worth celebrating.
The IPAC practitioner has done the lion's share of the work in reviewing the IPAC manual for the organization.
Some of this work could be delegated to members of the Infection Control Committee (ICC). The manual is
well laid out with hyperlinks to reference material. Older, out of date references and superseded policies are
not removed from the policy manual. In the interest of clarity, they probably should be. To ensure that the
IPAC manual is updated regularly, the ICC should include in its work plan a schedule of policy review to avoid
overwhelming the solo practitioner. This would require at most the discussion and review of no more than
two policies or procedures per regular meeting of ICC. Minutes should be taken during the discussions.
There is an innovative approach to hand hygiene audits where practitioners are encouraged to audit
themselves.
The age of the building has created some difficulties. Some plasticized surfaces are damaged and difficult to
clean. Posters on the wall should be laminated and date stamped for removal.
The last observation has to do with the involvement of the medical staff in hand hygiene. The medical staff is
not expected to participate in hand hygiene education. This is inconsistent with the expectations of other
service providers.
33
QMENTUM PROGRAM
3.2.6 Standards Set: Laboratory and Blood Services
Unmet Criteria
High Priority
Criteria
10.5
The laboratory reviews and updates the SOPs annually or more often if
needed.
CSA Reference: Z902-10, 4.6.1.6.
14.1
The laboratory has a sanitation and housekeeping program, and it follows
documented standard operating procedures (SOPs) for cleaning.
CSA Reference: Z902-10, 22.3, 22.3.2, 22.3.3.
ISO Reference: 15189-07, 5.2.10.
Laboratory leadership is committed to provide timely open communication to the staff. They involve the staff
in decision making and to provide opportunity of improvement to the quality of their staff work life.
Leadership provides encouragement and support for staff continuing education.
The nursing and medical staff is pleased with the communication, responsiveness to needs and support to
patient care. The laboratory services participate on several internal and regional committees.
Implementation of a complete formal program to assess competency for all aspects of laboratory disciplines
including both theoretical, practical knowledge and techniques has been started. Most SOP’s are reviewed
and recently approved since the last survey.
The organization is encouraged to monitor staff and lab user’s competency levels. SOP’s reviews should be
performed annually, prioritizing and continuous monitoring is encouraged to ensure completeness and
increase quality assurance.
Documentation of processes should be followed notably in the disinfection of work areas.
34
QMENTUM PROGRAM
3.2.7 Standards Set: Managing Medications
Unmet Criteria
High Priority
Criteria
Priority Process: Medication Management
6.1
Medication storage areas are clean and orderly.
7.3
Medications for client service areas are stocked in ready-to-use formats,
where available.
11.1
A pharmacist reviews prescription and medication orders prior to
dispensing.
11.2
Pharmacy staff review client medication allergies identified by the
pharmacy computer system prior to dispensing a medication.
11.3
Pharmacy staff review client medication interactions identified by the
pharmacy computer system prior to dispensing a medication.
13.3
The pharmacy dispenses medications in unit dose packaging.
Priority Process: Medication Management
The Shriner hospital is in a unique situation for the provision of pharmacy services. They have a service
contract with Montreal Children Hospital pharmacy. They do not have a pharmacy nor a pharmacist on site.
Prescriptions are sent once a day to the pharmacy to be processed. The pharmacy enters the prescription
into their pharmacy information system and only dispenses medications that are not ward stock. This
situation creates significant challenges for the organization. The relationship with the pharmacy will be
re-negotiated once the Shriner's hospital moves to their new site. At that point the Shriner will be able to
benefit from a full range of hospital based pharmacy services. In the meanwhile, nursing is committed and
dedicated in setting up systems to prevent medication errors. They have created innovative safety check
within their system. They administer medication mainly from ward stock. Nursing has developed a dose
validation process to reduce the risk of dosing error. This process appears to be effective. They work closely
with physicians to ensure that safety checks are respected. For a small hospital it is nice to note that they
have access to up to date drug information via the use of Lexi-Comp.
Lately they have procured new pumps with smart pump technology. The hospital has opted not to program a
drug library as they use a limited number of medications. It is suggested reconsidering this decision as smart
pump technology are designed to reduce human errors. The library may be limited to meet their needs.
The CPEO system has alert for drug interactions but does not seem to have dose validation for all drugs.
Formulary decisions are mirrored to the Montreal Children decisions and reviews as long as it fits the Shriner
needs. This ensures that surgeons working at both sites have access to the same therapeutic tools. Pharmacy
and therapeutic committee would fit better under medical leadership as this committee should report to MAC
as per Quebec structured.
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QMENTUM PROGRAM
3.2.8 Standards Set: Point-of-Care Testing
Unmet Criteria
High Priority
Criteria
Priority Process: Point-of-care Testing Services
Priority Process: Point-of-care Testing Services
A great deal has been accomplished since the last survey with the point-of-care testing quality assurance
program. Point of care testing is clearly understood throughout the organization to ensure appropriate
testing, monitoring and positive outcomes. The nursing staff is supported by the laboratory services with a
one-on-one training and the on-line training tool "Shine".
Laboratory leadership is encouraged to continue to audit and monitor nonconformities. A process for
ordering a point-of-care testing needs to be clarified and defined in the SHCIS system.
36
QMENTUM PROGRAM
3.2.9 Standards Set: Rehabilitation Services
Unmet Criteria
High Priority
Criteria
3.7
The interdisciplinary team follows a formal process to regularly evaluate its
functioning, identify priorities for action, and make improvements.
7.4
The team reconciles the client's medications upon admission to the
organization, with the involvement of the client, family or caregiver.
7.4.4
The team documents that the BPMH and admission medication
orders have been reconciled; and appropriate modifications to
medications have been made where necessary.
8.7
The team educates clients and families about their rights, and investigates
and resolves any claims that these rights have been violated.
10.5
The team has a process to evaluate client requests to bring in or
self-administer their own medication.
ROP
MAJOR
16.5
The team shares evaluation results with staff, clients, and families.
The rehabilitation team knows well the needs of clients and adapts the services when new needs merge.
The team is involved with partners and research department. The key focus is on children, family safety and
providing positive experience. The feedback of clients and families is considered and changes are made every
time it is possible.
The clinicians are members of their professional corporation. Their professional development is encouraged.
They are aware of best practices and research development.
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QMENTUM PROGRAM
The orientation guide is well organized and complete.
At the moment of the survey, the Family Guide was in process of revision and printing. The families and
patients we met did not receive information that is normally in the Family Guide. We encourage the
organization to distribute as soon as possible the new revised Family Guide that contains all information
needed about functioning of the center, way to complaint, their responsibilities on their own security, etc.
There is evidence that other documents and pamphlets are available for clients and families about the cares,
surgeries or services they will receive. These documents are attractive, informative and explicit.
One of the challenges for next months will be to increase the use of telehealth services especially with
clients from further regions.
The leader of rehabilitation service is also involved with the research department of the organization. This
way, clinicians are informed regularly on best practices and research results.
Evidence has shown that the orientation guide is precise, detailed and up to date. They normally accept
students three times a year and work with them for their research, for example.
Rehabilitation indicators are presented monthly to the management and also shared with staff. We encourage
the organization to share these results with clients and families too.
38
QMENTUM PROGRAM
3.2.10 Standards Set: Telehealth Services
Unmet Criteria
High Priority
Criteria
2.3
The organization identifies the human, financial, structural, and
informational resources needed to achieve the goals and objectives for
telehealth services.
The organization is well networked with the McGill University Network and the Shriners Hospital network.
There is a single telehealth station that can be moved to any of three locations within the hospital.
Physicians are enthusiastic about telehealth. The ambulatory care has a physician as a co-leader who is
helping with planning for telehealth in the new facility.
Telehealth is being included in the development of a scoliosis pathway for patients from British Columbia.
The policies and procedures for telehealth were last reviewed in 2006.
While there is a goal of increasing telehealth services by a fixed percentage, there does not appear to be an
overall plan to implement the strategic role of telehealth in achieving the organization's overall mission.
Uptake seems to be largely dependent on practitioner preference, not on deliberate planning. As the
organization expands its reach to other parts of Canada, this should become a planning priority.
39
QMENTUM PROGRAM
There is a clear process for ensuring practitioner competence.
The policies and procedures are well thought out but should be reviewed on a regular basis.
Privacy is adequately protected.
There is no roadmap outlining how the telemedicine service will be deployed.
40
QMENTUM PROGRAM
3.2.11 Priority Process: Surgical Procedures
Delivering safe surgical care, including preoperative preparation, operating room procedures, postoperative
recovery, and discharge
Unmet Criteria
High Priority
Criteria
Standards Set: Operating Rooms
1.3
The team uses evidence-based client care maps or pathways to guide them
through steps in the procedure, promote efficient care and achieve optimal
client outcomes.
Standards Set: Surgical Care Services
7.1
7.13
The team uses a procedure-specific care map to guide the client through
preparation for and recovery from the procedure.
The team reconciles the client's medications upon admission to the
organization, with the involvement of the client, family or caregiver.
7.13.4
The team documents that the BPMH and admission medication
orders have been reconciled; and appropriate modifications to
medications have been made where necessary.
12.1
The team maintains an accurate and up-to-date record for each client.
15.3
Staff and service providers participate in regular safety briefings to share
information about potential safety problems, reduce the risk of error, and
improve the quality of service.
ROP
MAJOR
The operating room is well organized and well managed. Clinical standards are maintained and enforced.
Access to rooms is well controlled. The rooms are engineered such that doors remain closed when not being
used. The surgical safety checklist is well conducted, both loud and proud. The purpose of the checklist is to
enhance team communication. The team at Shriners embraces this purpose fully. There is evidence of
technical and professional excellence throughout this part of the hospital; the organization is justifiably
proud of the work done here.
The organization is prepared to flash sterilize if needed, but has not done so and has removed the flash
sterilizer from the operating room. The performance of the operating room is benchmarked against standard
indicators for all Shriners hospitals and compares well.
Areas for improvement include the use of care mapping, safety engineered sharps, medication reconciliation
and clinical documentation. These are commented upon separately. In general, care mapping helps
standardize processes and allows an organization to better identify opportunities for improvement. The
hospital used to employ care maps before the electronic medical record was deployed and may wish to
re-integrate them into an electronic format. Clinical documentation standards should be reviewed.
Another area for improvement that is actively being considered is an increase in the percentage of first cases
of the day that start on time.
41
QMENTUM PROGRAM
Another area for improvement that is actively being considered is an increase in the percentage of first cases
of the day that start on time.
42
QMENTUM PROGRAM
Section 4
Instrument Results
As part of Qmentum, organizations administer instruments. Qmentum includes three instruments (or
questionnaires) that measure governance functioning, patient safety culture, and quality of worklife. They are
completed by a representative sample of clients, staff, senior leaders, board members, and other
stakeholders.
4.1 Governance Functioning Tool
The Governance Functioning Tool enables members of the governing body to assess board structures and
processes, provide their perceptions and opinions, and identify priorities for action. It does this by asking
questions about:
•
•
•
•
Board composition and membership
Scope of authority (roles and responsibilities)
Meeting processes
Evaluation of performance
Accreditation Canada provided the organization with detailed results from its Governance Functioning Tool prior
to the on-site survey through the client organization portal. The organization then had the opportunity to address
challenging areas.
• Data collection period: October 22, 2012 to January 11, 2013
• Number of responses: 18
Governance Functioning Tool Results
% Disagree
% Neutral
% Agree
Organization
Organization
Organization
%Agree
* Canadian
Average
1 We regularly review, understand, and ensure
compliance with applicable laws, legislation and
regulations.
0
0
100
92
2 Governance policies and procedures that define our
role and responsibilities are well-documented and
consistently followed.
0
6
94
95
3 We have sub-committees that have clearly-defined
roles and responsibilities.
0
0
100
96
4 Our roles and responsibilities are clearly identified
and distinguished from those delegated to the CEO
and/or senior management. We do not become
overly involved in management issues.
0
0
100
93
5 We each receive orientation that helps us to
understand the organization and its issues, and
supports high-quality decision-making.
0
0
100
92
Instrument Results
43
QMENTUM PROGRAM
% Disagree
% Neutral
% Agree
Organization
Organization
Organization
%Agree
* Canadian
Average
6 Disagreements are viewed as a search for solutions
rather than a “win/lose”.
0
6
94
93
7 Our meetings are held frequently enough to make
sure we are able to make timely decisions.
0
0
100
98
8 Individual members understand and carry out their
legal duties, roles and responsibilities, including
sub-committee work (as applicable).
0
0
100
95
9 Members come to meetings prepared to engage in
meaningful discussion and thoughtful
decision-making.
0
0
100
94
10 Our governance processes make sure that everyone
participates in decision-making.
0
6
94
93
11 Individual members are actively involved in
policy-making and strategic planning.
0
6
94
90
12 The composition of our governing body contributes
to high governance and leadership performance.
0
0
100
92
13 Our governing body’s dynamics enable group
dialogue and discussion. Individual members ask for
and listen to one another’s ideas and input.
0
0
100
95
14 Our ongoing education and professional development
is encouraged.
0
0
100
86
15 Working relationships among individual members and
committees are positive.
0
0
100
96
16 We have a process to set bylaws and corporate
policies.
0
0
100
95
17 Our bylaws and corporate policies cover
confidentiality and conflict of interest.
0
0
100
96
18 We formally evaluate our own performance on a
regular basis.
0
6
94
76
19 We benchmark our performance against other
similar organizations and/or national standards.
0
0
100
68
20 Contributions of individual members are reviewed
regularly.
6
11
83
66
Instrument Results
44
QMENTUM PROGRAM
% Disagree
% Neutral
% Agree
Organization
Organization
Organization
%Agree
* Canadian
Average
21 As a team, we regularly review how we function
together and how our governance processes could be
improved.
6
6
89
77
22 There is a process for improving individual
effectiveness when nonperformance is an issue.
6
28
67
59
23 We regularly identify areas for improvement and
engage in our own quality improvement activities.
0
6
94
82
24 As a governing body, we annually release a formal
statement of our achievements that is shared with
the organization’s staff as well as external partners
and the community.
0
17
83
84
25 As individual members, we receive adequate
feedback about our contribution to the governing
body.
6
0
94
68
26 Our chair has clear roles and responsibilities and
runs the governing body effectively.
0
6
94
94
27 We receive ongoing education on how to interpret
information on quality and patient safety
performance.
0
11
89
86
28 As a governing body, we oversee the development of
the organization’s strategic plan.
0
6
94
96
29 As a governing body, we hear stories about clients
that experienced harm during care.
0
11
89
83
30 The performance measures we track as a governing
body give us a good understanding of organizational
performance.
0
11
89
91
31 We actively recruit, recommend and/or select new
members based on needs for particular skills,
background, and experience.
6
0
94
91
32 We have explicit criteria to recruit and select new
members.
0
11
89
83
33 Our renewal cycle is appropriately managed to
ensure continuity on the governing body.
0
6
94
88
Instrument Results
45
QMENTUM PROGRAM
% Disagree
% Neutral
% Agree
Organization
Organization
Organization
%Agree
* Canadian
Average
34 The composition of our governing body allows us to
meet stakeholder and community needs.
0
0
100
93
35 Clear written policies define term lengths and limits
for individual members, as well as compensation.
0
6
94
92
36 We review our own structure, including size and
sub-committee structure.
0
0
100
87
37 We have a process to elect or appoint our chair.
6
17
78
92
*Canadian average: Percentage of Accreditation Canada client organizations that completed the instrument
from July to December, 2012 and agreed with the instrument items.
Instrument Results
46
QMENTUM PROGRAM
4.2 Patient Safety Culture Tool
Organizational culture is widely recognized as a significant driver in changing behavior and expectations in order
to increase safety within organizations. A key step in this process is the ability to measure the presence and
degree of safety culture. This is why Accreditation Canada provides organizations with the Patient Safety Culture
Tool, an evidence-informed questionnaire that provides insight into staff perceptions of patient safety. This tool
gives organizations an overall patient safety grade and measures a number of dimensions of patient safety
culture.
Results from the Patient Safety Culture Tool allow the organization to identify strengths and areas for
improvement in a number of areas related to patient safety and worklife.
Accreditation Canada provided the organization with detailed results from its Patient Safety Culture Tool prior to
the on-site survey through the client organization portal. The organization then had the opportunity to address
areas for improvement. During the on-site survey, surveyors reviewed progress made in those areas.
• Data collection period: September 18, 2012 to October 17, 2012
• Minimum responses rate (based on the number of eligible employees): 101
Instrument Results
47
QMENTUM PROGRAM
Patient Safety Culture: Results by Patient Safety Culture Dimension
100
90
80
Percentage Positive (%)
70
60
50
40
30
20
10
0
Senior leadership
support for safety
(valuing safety)
Communication
Supervisory leadership Patient safety learning
barriers/talking about
support for safety
culture
errors
Overall perception of
patient safety
79%
66%
79%
63%
88%
70%
61%
72%
53%
70%
Legend
* Canadian Average
Instrument Results
48
QMENTUM PROGRAM
4.3 Worklife Pulse Tool
Accreditation Canada helps organizations create high quality workplaces that support workforce wellbeing and
performance. This is why Accreditation Canada provides organizations with the Worklife Pulse Tool, an
evidence-informed questionnaire that takes a snapshot of the quality of worklife.
Organizations can use results from the Worklife Pulse Tool to identify strengths and gaps in the quality of
worklife, engage stakeholders in discussions of opportunities for improvement, plan interventions to improve the
quality of worklife and develop a clearer understanding of how quality of worklife influences the organization's
capacity to meet its strategic goals. By taking action to improve the determinants of worklife measured in the
Worklife Pulse tool, organizations can improve outcomes.
Accreditation Canada provided the organization with detailed results from its Worklife Pulse Tool prior to the
on-site survey through the client organization portal. The organization then had the opportunity to address areas
for improvement. During the on-site survey, surveyors reviewed progress made in those areas.
• Data collection period: September 18, 2012 to October 17, 2012
• Minimum responses rate (based on the number of eligible employees): 110
Instrument Results
49
QMENTUM PROGRAM
Worklife Pulse Tool: Results of Work Environment
100
90
80
Percentage Positive (%)
70
60
50
40
30
20
10
0
Job
Training and
Development
Coworkers
Immediate
Supervisor
Senior
Management
Safety and
Health
Overall
Experience
82%
64%
89%
79%
77%
86%
86%
74%
64%
81%
75%
63%
77%
67%
Legend
* Canadian Average
Instrument Results
50
QMENTUM PROGRAM
Client Experience Tool
Measuring client experience in a consistent, formal way provides organizations with information they
can use to enhance client-centred services, increase client engagement, and inform quality
improvement initiatives.
Prior to the on-site survey, the organization conducted a client experience survey that addressed the
following dimensions:
Respecting client values, expressed needs and preferences,including respecting client rights,
cultural values, and preferences; ensuring informed consent and shared decision-making; and
encouraging active participation in care planning and service delivery
Sharing information, communication, and education,including providing the information that
people want, ensuring open and transparent communication, and educating clients and their
families about the health issues
Coordinating and integrating services across boundaries,including accessing services,
providing continuous service across the continuum, and preparing clients for discharge or
transition
Enhancing quality of life in the care environment and in activities of daily living,including
providing physical comfort, pain management, and emotional and spiritual support and
counselling
The organization then had the chance to address opportunities for improvement, and to discuss
related initiatives with surveyors during the on-site survey.
Client Experience Program Requirement
Conducted a client experience survey using a survey tool and approach that
meets accreditation program requirements
Met
Provided a client experience survey report(s) to Accreditation Canada
Met
Instrument Results
51
QMENTUM PROGRAM
Appendix A
Qmentum
Health care accreditation contributes to quality improvement and patient safety by enabling a health
organization to regularly and consistently assess and improve its services. Accreditation Canada's Qmentum
accreditation program offers a customized process aligned with each client organization's needs and priorities.
As part of the Qmentum accreditation process, client organizations complete self-assessment questionnaires,
submit performance measure data, and undergo an on-site survey during which trained peer surveyors assess their
services against national standards. The surveyor team provides preliminary results to the organization at the end
of the on-site survey. Accreditation Canada reviews these results and issues the Accreditation Report within 10
business days.
An important adjunct to the Accreditation Report is the online Quality Performance Roadmap, available to client
organizations through their portal. The organization uses the information in the Roadmap in conjunction with the
Accreditation Report to ensure that it develops comprehensive action plans.
Throughout the four-year cycle, Accreditation Canada provides ongoing liaison and support to help the
organization address issues, develop action plans, and monitor progress.
Action Planning
Following the on-site survey, the organization uses the information in its Accreditation Report and Quality
Performance Roadmap to develop action plans to address areas identified as needing improvement. The
organization provides Accreditation Canada with evidence of the actions it has taken to address these required
follow ups.
Evidence Review and Ongoing Improvement
Five months after the on-site survey, Accreditation Canada evaluates the evidence submitted by the organization.
If the evidence shows that a sufficient percentage of previously unmet criteria are now met, a new accreditation
decision that reflects the organization's progress may be issued.
Qmentum
52
QMENTUM PROGRAM
Appendix B
Priority Processes
Priority processes associated with system-wide standards
Priority Process
Description
Communication
Communicating effectively at all levels of the organization and with external
stakeholders
Emergency Preparedness
Planning for and managing emergencies, disasters, or other aspects of public
safety
Governance
Meeting the demands for excellence in governance practice.
Human Capital
Developing the human resource capacity to deliver safe, high quality services
Integrated Quality
Management
Using a proactive, systematic, and ongoing process to manage and integrate
quality and achieve organizational goals and objectives
Medical Devices and
Equipment
Obtaining and maintaining machinery and technologies used to diagnose and
treat health problems
Patient Flow
Assessing the smooth and timely movement of clients and families through
service settings
Physical Environment
Providing appropriate and safe structures and facilities to achieve the
organization's mission, vision, and goals
Planning and Service Design
Developing and implementing infrastructure, programs, and services to meet
the needs of the populations and communities served
Principle-based Care and
Decision Making
Identifying and decision making regarding ethical dilemmas and problems.
Resource Management
Monitoring, administration, and integration of activities involved with the
appropriate allocation and use of resources.
Priority processes associated with population-specific standards
Priority Process
Description
Chronic Disease Management
Integrating and coordinating services across the continuum of care for
populations with chronic conditions
Population Health and
Wellness
Promoting and protecting the health of the populations and communities
served, through leadership, partnership, innovation, and action.
Priority Processes
53
QMENTUM PROGRAM
Priority processes associated with service excellence standards
Priority Process
Description
Blood Services
Handling blood and blood components safely, including donor selection, blood
collection, and transfusions
Clinical Leadership
Providing leadership and overall goals and direction to the team of people
providing services.
Competency
Developing a skilled, knowledgeable, interdisciplinary team that can manage
and deliver effective programs and services
Decision Support
Using information, research, data, and technology to support management
and clinical decision making
Diagnostic Services: Imaging
Ensuring the availability of diagnostic imaging services to assist medical
professionals in diagnosing and monitoring health conditions
Diagnostic Services:
Laboratory
Ensuring the availability of laboratory services to assist medical professionals
in diagnosing and monitoring health conditions
Episode of Care
Providing clients with coordinated services from their first encounter with a
health care provider through their last contact related to their health issue
Impact on Outcomes
Identifying and monitoring process and outcome measures to evaluate and
improve service quality and client outcomes
Infection Prevention and
Control
Implementing measures to prevent and reduce the acquisition and
transmission of infection among staff, service providers, clients, and families
Medication Management
Using interdisciplinary teams to manage the provision of medication to clients
Organ and Tissue Donation
Providing organ donation services for deceased donors and their families,
including identifying potential donors, approaching families, and recovering
organs
Organ and Tissue Transplant
Providing organ transplant services, from initial assessment of transplant
candidates to providing follow-up care to recipients
Organ Donation (Living)
Providing organ donation services for living donors, including supporting
potential donors to make informed decisions, conducting donor suitability
testing, and carrying out donation procedures
Point-of-care Testing
Services
Using non-laboratory tests delivered at the point of care to determine the
presence of health problems
Priority Processes
54
QMENTUM PROGRAM
Priority Process
Description
Primary Care Clinical
Encounter
Providing primary care in the clinical setting, including making primary care
services accessible, completing the encounter, and coordinating services
Surgical Procedures
Delivering safe surgical care, including preoperative preparation, operating
room procedures, postoperative recovery, and discharge
Priority Processes
55

Accreditation Report - Shriners Hospitals for Children

Transcription

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