accreditation primer report - schc · accreditation primer report 1.2 about the on-site survey •...

Accreditation Primer Report

Scarborough Centre for HealthyCommunitiesScarborough, ON

On-site survey dates:

Report issued:

April 27, 2015 - April 30, 2015

May 13, 2015

Accredited by ISQua

Confidentiality

This report is confidential. Accreditation Canada only provides it to the organization; it is not released to anyother parties.

In the interest of transparency and accountability, Accreditation Canada encourages the organization todisseminate its Accreditation Primer Report to staff, board members, clients, the community, and otherstakeholders.

Any alteration of this Accreditation Primer Report compromises the integrity of the accreditation process and isstrictly prohibited.

About the Accreditation Primer Report

Scarborough Centre for Healthy Communities (referred to in this report as “the organization”) is participating inAccreditation Canada's Accreditation Primer program. As part of this ongoing process of quality improvement, anon-site survey was conducted in April 2015. Information from the on-site survey was used to produce thisAccreditation Primer Report.

Accreditation Primer results are based on information provided by the organization. Accreditation Canada relieson the accuracy of this information to plan and conduct the on-site survey and produce the Accreditation PrimerReport.

ACCREDITATION PRIMER REPORT

© Accreditation Canada, 2015

A Message from Accreditation Canada's President and CEO

On behalf of the Board of Directors of Accreditation Canada, I would like to extend my sincere congratulations toyour Board, your leadership team, and your staff on your participation in the Accreditation Primer. As the firststep in your quality journey with Accreditation Canada, I am confident that the process will be helpful inidentifying strengths and areas where your organization can focus its quality and safety improvement efforts. TheAccreditation Primer is how organizations begin to realize the full value of our Qmentum program.

Attached for your review is your Accreditation Primer Report, which includes the accreditation decision and thefinal results from your organization's on-site survey. The information in this report, as well as your online QualityPerformance Roadmap, is designed to guide your organization's quality improvement activities.

Thank you for your leadership and for demonstrating your ongoing commitment to quality by partnering withAccreditation Canada on your quality journey.

As always, your feedback is welcome. We too are focused on improvement, and your input provides us with anopportunity to strengthen our program to ensure that it remains relevant to your organization.

Should you have any questions, your Accreditation Specialist is available to assist you.

I look forward to our continued partnership.

Sincerely,

Wendy NicklinPresident and Chief Executive Officer


A Message from Accreditation Canada's President and CEO

Table of Contents

1.0 Executive Summary 1

1.1 Accreditation Decision 1

1.2 About the On-site Survey 2

1.3 Overview by Quality Dimensions 3

1.4 Overview by Standards 4

1.5 Summary of Surveyor Team Observations 5

2.0 Detailed On-site Survey Results 6

2.1 Priority Process Results for System-wide Standards 7

2.1.1 Priority Process: Planning and Service Design 7

2.1.2 Priority Process: Human Capital 8

2.1.3 Priority Process: Integrated Quality Management 9

2.1.4 Priority Process: Physical Environment 10

2.1.5 Priority Process: Emergency Preparedness 11

2.1.6 Priority Process: Medical Devices and Equipment 12

2.2 Service Excellence Standards Results 13

2.2.1 Standards Set: Primer 13

2.2.2 Priority Process: Infection Prevention and Control for Primer 17

2.2.3 Priority Process: Medication Management for Primer 18

Appendix A Accreditation Primer 19


iTable of ContentsAccreditation PrimerReport

Scarborough Centre for Healthy Communities (referred to in this report as “the organization”) is participating inthe Accreditation Canada Accreditation Primer program. This is the first step on its quality improvement journeywith Accreditation Canada—an independent, not-for-profit organization that sets standards for quality and safetyin health care and accredits health care organizations in Canada and around the world.

The Accreditation Primer program involves an evaluation of the quality and safety of the organization's programsand services. Following a comprehensive self-assessment, external peer surveyors conducted an on-site surveyduring which they assessed the organization against Accreditation Canada standards. The results are included inthis 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 incorporatequality improvement principles into its programs, policies, and practices. At this point, we congratulate theorganization and encourage it to continue its journey to begin the Qmentum program.

The organization is commended on its use of accreditation to improve the services it offers to clients and thecommunity.

1.1 Accreditation Decision

Scarborough Centre for Healthy Communities's accreditation decision is:

Take action and proceed

The organization has achieved Accreditation Primer Award Accreditation Canada recommends that theorganization create a plan to address the items identified with red and yellow flags. The organization shouldcontact its Accreditation Specialist to discuss strategies for success as it begins Qmentum.


Executive SummarySection 1

Executive Summary 1Accreditation Primer Report


1.2 About the On-site Survey

• On-site survey dates: April 27, 2015 to April 30, 2015

• Locations

The following locations were assessed during the on-site survey. All sites and services offered by theorganization are deemed accredited.

1 2660 Eglinton Ave. E. --The Hub

2 4002 Sheppard Ave. E.

3 4100 Lawrence Ave. E.




7 629 Markham road

• Standards

The Primer Standards were used to assess the organization's programs and services during the on-site survey:

Primer1



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 criteriarelated to each dimension that were rated as met, unmet, or not applicable.

Quality Dimension Met Unmet N/A Total

Population Focus (Work with my community toanticipate and meet our needs) 2 0 0 2

Accessibility (Give me timely and equitableservices) 2 0 0 2

Safety (Keep me safe)33 5 1 39

Worklife (Take care of those who take care of me)9 0 0 9

Client-centred Services (Partner with me and myfamily in our care) 9 1 0 10

Continuity of Services (Coordinate my care acrossthe continuum) 9 0 0 9

Appropriateness (Do the right thing to achieve thebest results) 24 2 0 26

Total 88 8 1 97



1.4 Overview by Standards

The Accreditation Primer is an opportunity for the organization and Accreditation Canada to work together toestablish the supports, structures, and processes necessary for accreditation, with a particular focus on thefundamental elements of quality and safety. Accreditation Canada's programs use national standards to assistorganizations in improving the quality and safety of their services. Results from on-site surveys are used by theorganization to identify areas for improvement and determine priorities for action.

The Accreditation Primer standards identify policies and practices that contribute to high-quality, safe, andeffectively-managed care. This table shows standards used to evaluate the organization's programs and services,and the number and percentage of criteria that were met, unmet, or not applicable during the on-site survey.

Standards SetMet Unmet N/A

Total Criteria

# (%) # (%) #

Primer 88(91.7%)

8(8.3%)

1

88(91.7%)

8(8.3%)

1Total



The surveyor team made the following observations about the organization's overall strengths,opportunities for improvement, and challenges.

1.5 Summary of Surveyor Team Observations

The organization, Scarborough Centre for Healthy Communities (SCHC), is commended on preparing for andparticipating in Accreditation Canada's Primer survey process. The SCHC is a well-established and growingorganization providing a variety of primary care and community health services for the Scarborough community.

The organization assesses the community needs using numerous mechanisms and data sources, and is responsiveto the community’s changing demographics. The organization is respected in the community. The SCHC isdelivering services to individuals with often complex needs who are part of groups and cultures that are difficultto reach. Approximately seventy percent (70%) of the organization’s new primary care clients are not insured,having recently arrived in Canada. During the survey the holistic and client-centred approach to care wasconsistently evident. The organization values its community partnerships and is successful in communityengagement and in partnering both internally and externally. This is evidenced by the Hub, which is amulti-agency service group where numerous community agencies are available at one location. The SCHC is theorganizing and coordinating agency for the Hub.

Scarborough Centre for Healthy Communities (SCHC) has a dedicated and enthusiastic leadership team that hasmade the engagement of staff members a priority. Management and committee structures have been refined topromote staff engagement and facilitate inter-team/inter-site collaboration and relationship building. The newlyformed inter-professional committee, in particular, is receiving praise from staff members that view this as amechanism to enhance collaboration. One of the noted strengths of this organization is its dedicated,enthusiastic and caring group of staff. Staff members report feeling engaged in the organization and in thedecision-making process.

The leadership team has also made quality and safety a priority. A relatively new quality committee andeffective mechanisms to stimulate a quality conversation amongst all staff members are proving effective. Infact, quality improvement is now routinely discussed by all teams during huddles, using visual quality boards as aguide. Quality improvement efforts link directly to the organizational strategic plan via the balanced scorecardof performance indicators, which is also reflected in operational plans and individual performance objectives.

The organization is undergoing a significant number of changes, including new committee structures, reportingrelationships, and procedures, much of which is driven by the pursuit of quality improvement. Maintaining thebehavioural change may prove challenging for SCHC; ongoing monitoring and evaluation of initiatives areencouraged.

The organization has made a great start in improving client safety. Some noteworthy initial progress has beenmade toward improving client safety in medication reconciliation, falls prevention programs, hand hygiene, anddevelopment of documented clients' rights and responsibilities. Scarborough Centre for Healthy Communities isencouraged to continue its pursuit of these and other quality and safety initiatives in order to attain a standardof excellence across the organization.



Detailed On-site Survey ResultsSection 2

This section provides the detailed results of the on-site survey. Results are presented by priority process andstandard set.

Accreditation Canada defines priority processes as critical areas and systems that have a significant impact on thequality and safety of care and services. Priority processes provide a different perspective from that offered bythe standards, organizing the results into themes that cut across departments, services, and teams.

For instance, the episode of care priority process includes criteria from a number of sections in the AccreditationPrimer standards that address various aspects of client care. These include intake or admitting, assessment,service planning, service delivery, follow up, and transitions. This provides a comprehensive picture of the careclients receive as they move through the organization.

During the on-site survey, surveyors rate the organization's compliance with the criteria, provide rationale for therating, and comment on each priority process.

Priority process comments are below. The rationale for unmet criteria can be found in the organization's onlineQuality Performance Roadmap.

Detailed On-site Survey Results 6Accreditation Primer Report


2.1 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 criteriathat also relate to services should be shared with the relevant team.

2.1.1 Priority Process: Planning and Service Design

Developing and implementing infrastructure, programs, and services to meet the needs of the populations andcommunities served

The organization has met all criteria for this priority process.

Surveyor comments on the priority process(es)

The organization gathers information about the needs of the community by using a variety of mechanisms. Ittakes steps to fill in gaps in the data regarding community needs by way of focus groups and surveys. There isevidence that programs and services are planned, designed and modified based on the assessed needs of thecommunity.

The organization is congratulated on its processes for ensuring congruence of plans and monitoring from thestrategic plan to the balanced scorecard to area annual operational plans and to individual employeeperformance development plans and dialogues. This effort clearly ties the activities of individual staffmembers to strategic objectives in such a way that every employee can see his or her direct contribution tothe overall mission of the organization.

Scarborough Centre for Healthy Communities (SCHC) is commended for its ability to facilitate partnershipswith other organizations in the community. Community services such as the Family Resource Centre and FoodBank are located within Toronto Housing Corporation buildings rent free. The development of the Hub hasallowed a variety of community agencies to co-locate and work more collaboratively to the benefit of clients.



2.1.2 Priority Process: Human Capital

Developing the human resource capacity to deliver safe, high quality services



The organization has taken a number of steps towards improving staff engagement. Position profiles havebeen updated and are available for all positions and accessible via the electronic document managementsystem, thus making the descriptions available and transparent to all staff. More than eighty-five percent(85%) of staff members have received a performance evaluation in the past year. The performance dialogueshave included establishing performance objectives for the upcoming year which are clearly linked to theperformance measures of the organization's overall balanced scorecard. Commendation is given for thiseffective mechanism which serves to demonstrate to employees their role and value in meeting the overallmission and vision of Scarborough Centre for Healthy Communities (SCHC).

A number of activities have been implemented to build stronger knowledge and working relationships forstaff across programs and the eleven service locations. In general, staff members report appreciation for thestrengthened feeling of connectedness to the organization and also for the positive working relationshipsthroughout. Activities have included social events, newsletters and a unique speed-dating style engagementactivity.

The organization is recognized for establishing organization-wide committees on quality and professionalpractice, which includes responsibility for ethics. The inter-professional practice committee includesdiscipline-specific sub groups. These groups are in the process of forming and will provide aprofession-specific venue for discussion of best practices, scope of practice and undertaking peer casestudies.

The organization works with a significant number of volunteers and is commended for its effectiverecruitment and on boarding practices for volunteers. Currently, performance evaluation of volunteers isencouraged but conducted informally. The organization is encouraged to formalize volunteer performanceevaluation practices.



2.1.3 Priority Process: Integrated Quality Management

Using a proactive, systematic, and ongoing process to manage and integrate quality and achieve organizationalgoals and objectives

Unmet Criteria

Standards Set: Primer

The organization's leaders provide quarterly reports on client safety to theirgoverning body.

2.7


The organization's enthusiasm for quality is palpable, and can be seen in all interactions with managementand staff. The organization is commended for instilling a quality culture with a foundation on the principlesof LEAN management and Plan Do Study Act (PDSA). The establishment of a cross-departmental qualityimprovement committee in the past several months has proven effective in unifying the pursuit of qualityacross the organization.

The organization has recently implemented a quality management program through which anorganization-wide balanced scorecard of indicators influence operational plans and indicators at the frontline. Twenty quality display boards including activities, goals, challenges and successes, have beenimplemented in all areas to provide for visualization of a quality improvement focus for all team members. Insome areas, the quality board is used as a focal point for staff huddles, thereby keeping staff members awareof and engaged in quality improvement initiatives. The organization is commended for implementing thisvisual quality management tool. Encouragement is offered to continue using this tool as a venue to highlightcharts and diagrams of performance indicators. Staff members particularly appreciate the “quality idea” and“fire starter” sections of the boards. The organization is further encouraged to evaluate the utilization of theboards and take steps to identify leading practices and spread to all areas.

The organization has a reporting process in place for staff members and/or others to report adverse eventsand near misses, and regularly reviews reported events. Encouragement is offered to move forward withplans to produce aggregate reports of all events organization-wide on a monthly basis for trending andidentification of opportunities for improvement. The organization is encouraged to provide aggregate reportsto the board of directors at least quarterly.

The organization has recently developed an ethics review committee embedded in its committee structure.An ethics framework has been developed and adopted. The board of directors and senior leadership havebeen educated on the framework. The committee provides research ethics review which takes into accountthe decisions of research ethics boards at academic or health facilities reviewing the same researchinitiatives. The committee is also available for ethics consultation regarding clinical dilemmas, whichprimarily involve the provision of service to uninsured or out-of-region clients.The ethics committee hasestablished linkages with a local hospital for access to a qualified health ethicist for consultation.



2.1.4 Priority Process: Physical Environment

Providing appropriate and safe structures and facilities to achieve the organization's mission, vision, and goals



The organization carries out its operations in eleven locations. Good processes are in place to ensureappropriate safety of the physical environments, with a good understanding of responsibilities between theorganization and the landlords for each of these locations.

The occupational health and safety committee audits the physical environment monthly.



2.1.5 Priority Process: Emergency Preparedness

Planning for and managing emergencies, disasters, or other aspects of public safety



The recently developed disaster and emergency preparedness plan will be improved as the organizationlearns from drills and real events. The organization is commended on the formal debriefing process anddocumentation which facilitates learning from every event and situation. Formalizing the process ofincorporating feedback into the plan will be an important next step. Staff members are still learning aboutthe plan and expectations. Continued and ongoing training and drills will be important in ensuring fullreadiness for emergency situations.

There are plans to continue to develop the plan to include other situations such as power outages, naturaldisasters and other emergency situations.



2.1.6 Priority Process: Medical Devices and Equipment

Obtaining and maintaining machinery and technologies used to diagnose and treat health problems



The organization has a process to ensure preventive maintenance occurs on all medical devices, vaccinerefrigerators and other equipment. Scarborough Centre for Healthy Communities (SCHC) has a fleet of tenvehicles and each of these is also on a preventive maintenance schedule.

Staff members have written procedures and logs for sterilization procedures. Vaccine refrigerator outageshave occurred and alarms are in place. Improvements have been instituted. Given that only minimal weekendmonitoring occurs (none on Sundays), and given the impact on cold chain, the organization may wish toconsider weekend monitoring.



2.2 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:

Primary Care Clinical Encounter

Providing primary care in the clinical setting, including making primary care services accessible, completingthe encounter, and coordinating services

Infection Prevention and Control for Primer

Implementing measures to prevent and reduce the acquisition and transmission of infection among staff,service providers, clients, and families

Medication Management for Primer

Using interdisciplinary teams to manage the provision of medication to clients

Competency

Developing a skilled, knowledgeable, interdisciplinary team that can manage and deliver effective programsand services

Episode of Care

Providing clients with coordinated services from their first encounter with a health care provider throughtheir 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 clientoutcomes

2.2.1 Standards Set: Primer

Unmet Criteria

Priority Process: Primary Care Clinical Encounter


Priority Process: Competency


Priority Process: Episode of Care



The team reconciles clients' medications at the beginning and end ofservice, when medication management is a component of care.

8.9

The team completes a timely health assessment for each client.9.3

The team educates clients and families about their rights, and investigatesany claims that these rights have been violated.

9.7

The team monitors whether clients' goals and expected results for care andservices are achieved, and uses this information to identify barriers toachieving goals.

9.13

Priority Process: Decision Support


Priority Process: Impact on Outcomes

The organization provides clients and their families with written and verbalinformation about the client's role in promoting safety.

2.4

The team implements and evaluates a falls prevention strategy to minimizeclient injury from falls.

13.4


Priority Process: Primary Care Clinical Encounter

A most responsible clinician is designated as the system navigator. In some cases this is the social worker andin others it is the primary care provider. For primary care services, the physician or nurse practitioner playthis role.

Recently, the organization improved access by offering quick access appointments.This was a result ofpatient dissatisfaction with urgent appointments. Feedback has improved. The organization has implementedadvanced access accessibility interventions to ensure that same-day access to primary care services isavailable. Utilization is monitored regularly from a quality improvement perspective. All clinicians are able toaccommodate same-day appointments if necessary.

Based on client satisfaction feedback, clinic operating times have been extended. After-hours access toservices is offered twice or three times per week in the evening, and on every other Saturday. In addition,people can access other clinics or hospitals if the situation is urgent.

Abnormal lab results are noted by the nurse and in the health record, and follow-up is flagged for the primarycare provider. Clinicians check their abnormal results every morning before starting their day. The systemalerts in red if the values are not normal. Processes are in place for critical values to be communicatedimmediately and it includes alternate coverage of responsibility if a clinician is off work. All critical resultsare immediately brought to the attention of the most responsible primary care provider, and this is done bythe nurse that reviewed the results.

primary care services. The concept of self-care is deeply embedded in the practice paradigm. A goodexample of this is chiropodist care where the client is continuously educated on how to care for their feetthemselves.



Priority Process: Competency

The organization is commended for its efforts at ensuring that performance development reviews areup-to-date for all staff. Currently, more that eighty-five (85%) of employees have a documented review ofprevious performance, and have established performance objectives for the upcoming year.

The organization is encouraged to formalize and document performance review conversations withvolunteers.

Staff members are provided with an organization orientation as well as an orientation specific to their workareas. The organization is encouraged to consider the use of an orientation check list specific to each positionto ensure all aspects of the orientation are covered.

The organization supports staff professional development by way of in services, educational offerings andsupport of requests for external education. A consistent approach across the organization may provebeneficial as it would provide consistency in the types of requests supported and the level of support given.

Priority Process: Episode of Care

For primary care encounters, the organization has recently established a medication reconciliation process.This process is being implemented in a staged manner starting with new clients and during follow-up visits.The team is encouraged to pursue its plans to fully implement medication management..

The initial assessment is consistently completed at the time of intake. Teams however, are inconsistentregarding the frequency at which clients are reassessed over time for the purposes of assessment and careplanning. Frequency can range from the time to reassessment sometimes being several years in the Adult Dayprogram. Establishing a regular interval for routine reassessment is encouraged.

Every client has a documented plan of care. However, in Home Support services and Adult Day program thecare plan consists primarily of a list of services to be provided, based on the initial assessment. Theorganization is encouraged to consider a care plan format and methodology which includes the developmentof realistic, measurable goals developed in collaboration with the patient and family. The Adult Day programhas established a new care planning tool which includes establishing and monitoring of goals, and isencouraged to proceed toward implementation of this newly developed methodology.

For primary care clients, individual care plan goals are monitored by clinicians. Monitoring the best practiceguideline for adherence for chronic diseases could be enhanced with better electronic tools to flag clinicians.Clinicians are focused on client goals and progress towards the goal. The team is further encouraged toensure that progress toward goal attainment is assessed, with care approaches modified accordingly.

Initial assessment by the social worker is done for non-insured clients/patients. A nurse does the initialassessment and triage of insured patients. Once these are completed an appointment with a primary careprovider is arranged.

Sheppard, the teams use a problem-oriented approach to charting and for each problem there is a goal.Clinicians monitor progress towards the goal.

The clients sign consents for release of information to the care team on admission. Consent to treatment iscollected for treatment such as minor surgery.

Written material about clients' bill of rights is not yet available. Although clinicians attempt to educate, thiscannot be done consistently using verbal approaches. The organization is encouraged to implement processesfor effectively informing clients of their rights and responsibilities.


The organization works in teams and the complex care of many clients requires multidisciplinary andmulti-team involvement. Self-management education is a major part of the diabetes program and theprimary care services. The concept of self-care is deeply embedded in the practice paradigm. A goodexample of this is chiropodist care where the client is continuously educated on how to care for their feetthemselves.


Sheppard, the teams use a problem-oriented approach to charting and for each problem there is a goal.Clinicians monitor progress towards the goal.

The clients sign consents for release of information to the care team on admission. Consent to treatment iscollected for treatment such as minor surgery.

Written material about clients' bill of rights is not yet available. Although clinicians attempt to educate, thiscannot be done consistently using verbal approaches. The organization is encouraged to implement processesfor effectively informing clients of their rights and responsibilities.

Priority Process: Decision Support

The organization has a variety of record keeping mechanisms. Clinical teams make effective use of theNightingale system, and community teams utilize the CIMS system which includes the resident assessmentinstrument community health assessment (InterRAI-CHA) tool.

The electronic medical record provides a standardized process for the collection, entering and recording ofinformation. In Primary Care, the electronic record is used for collecting, entering, using and recordinginformation. Some limitations of the system cause the team to use paper tools for some items such as thenurse starting the encounter for a physical examination.

In community services, CIMS information is augmented with the use of paper records. In Home Supportservices for example, a paper record is maintained for the care plan along with a flow sheet of daily serviceprovision with limited progress notes. Because the active daily flow sheets are maintained separately fromthe remainder of the client file, regular access to assessment information and care plans is cumbersome.

Priority Process: Impact on Outcomes

Materials on the patient or client role in safety are in development. The organization is encouraged toimplement mechanisms for communicating to clients and families about their role in safety as soon aspossible.

While the organization has a number of falls prevention strategies in place, these have only recently beenarticulated in a comprehensive falls assessment strategy. The strategy includes home safety assessmentcheck-lists, individual client assessments using the resident assessment instrument community healthassessment (InterRAI-CHA) and get-up-and-go tests, physical exercise and education. Four performancemeasures have been identified, including the number of reported falls.The organization is encouraged toevaluate the effectiveness of the falls prevention strategy.


At the Hub, the teams monitor progress against the goals set with clients/patients. For chronic diseases suchas diabetes the electronic client record system could provide for ease of monitoring these clients. At 4002


2.2.2 Priority Process: Infection Prevention and Control for Primer

Implementing measures to prevent and reduce the acquisition and transmission of infection among staff, serviceproviders, clients, and families



The organization engaged a consulting firm to recommend a path to meet infection prevention and control(IPAC) standards. The report provides an organizational road map by dealing with the highest risk areas first.Oversight by the quality and safety committee in terms of progress is recommended.

The hand-hygiene campaign has proven successful. There is wide availability of hand sanitizer, hand washingstations and visible signage. Staff members and clients are aware of the importance of hand washing. Thenext step will be to conduct hand-hygiene audits to quantify the rate of compliance, and further motivatethe teams.

A number of new IPAC policies are in place to meet the standards. The immunization policy for staff membersstrongly encourages immunization but does not make it mandatory. Reporting on staff rate of fluimmunization can further promote immunization.



2.2.3 Priority Process: Medication Management for Primer

Using interdisciplinary teams to manage the provision of medication to clients

Unmet Criteria

Standards Set: Primer

The organization reviews medication errors and near misses to identify andaddress areas for improvement.

8.12


The organization has implemented a number of improvements to meet standards regarding medicationmanagement. Policies have been developed that include making the roles and responsibilities of staffmembers clear. All clinical staff members have access to current resources to guide their decisions.

Safety in medication practices is evident with abbreviations that are prohibited from being prominentlydisplayed. No prohibited abbreviations were noted in documentation reviewed during the on-site survey.

Medication reconciliation has commenced in the community health centre, with the nurse beginning theprocess on new admissions and physical examinations. Clients are asked to bring in medication and their useis discussed. The nurse identifies variances and the primary care provider must work with the client and/ orpharmacy/ family to remedy. The process is still evolving and the team is recommended to evaluate theeffectiveness of the process over time. The organization may wish to consider partnering with a pharmacistas it reviews the process.



Accreditation PrimerAppendix A

Health care accreditation contributes to quality improvement and patient safety by enabling a healthorganization to regularly and consistently assess and improve its services. The Accreditation Primer programoffers a customized process aligned with each client organization's needs and priorities.

As part of the Accreditation Primer process, organizations complete a Self-Assessment, have the option ofcompleting and submitting survey instrument data, and undergo an on-site survey during which trained peersurveyors assess their services against national standards. The surveyor team provides preliminary results to theorganization at the end of the on-site survey. Accreditation Canada reviews these results and issues theAccreditation Primer Report within 10 business days.

An important adjunct to the Accreditation Primer Report is the online Quality Performance Roadmap (QPR),available to the organization through its portal. The organization uses the information in the QPR in conjunctionwith the Accreditation Primer Report to develop comprehensive action plans.

Throughout the Accreditation Primer program, Accreditation Canada provides ongoing support to help theorganization address issues, develop action plans, and monitor progress.

Following the on-site survey, the organization uses the information in its Accreditation Primer Report and QPR todevelop action plans to address areas identified as needing improvement. The organization uses this informationto make continuous quality improvements so it can begin the Qmentum program.

Action Planning

Accreditation Primer 19Accreditation Primer Report

accreditation primer report - schc · accreditation primer report 1.2 about the on-site survey •...

Documents