Our Connection - Spring 2023

Special Accreditation Issue – June 2023

Accreditation information

This special accreditation edition provides staff, physicians and volunteers with valuable information to prepare for the survey. Additional resources can be found on SharePoint. If you have any questions please contact your leader or: Jennifer.Payton@sjhc.london.on.ca

How does an accreditation survey work?

Accreditation is a quality improvement process; it helps our organization identify what we’re doing well and where we need to focus our improvement efforts. It allows us to assess a broad range of services and understand how to make better use of resources, increase efficiency, enhance quality and safety and reduce risk. It also helps St. Joseph’s define and measure the quality of our care against national standards of excellence.

Accreditation involves all members of the St. Joseph’s family, across all sites and locations; from our board of directors and volunteers to direct-care and support staff, as well as members of the community including patients, residents, families and care partners. Exceptional care involves all of us.

An on-site survey is conducted by trained peer surveyors who assess the organization against national standards. The surveyors are health care professionals and administrators from accredited health care organizations. After the on-site survey, the surveyors submit a preliminary report to the health care organization and to Accreditation Canada.

Accreditation Canada examines the surveyors’ report and provides the organization with a final report and an accreditation decision based on the on-site survey. The results of the on-site survey point to areas of success and areas where improvements can be made; the latter are used to bolster the organization’s ongoing quality improvement program.

The accreditation decision lasts for four years.

This October, St. Joseph’s will once again be welcoming Accreditation Canada surveyors to our organization.

SPECIAL ACCREDITATION ISSUE – Preparing for our on-site survey

Communication summaries

To ensure staff and physicians have the information they need to feel confident about the survey, communication summaries related to Required Organizational Practices (ROPs) and other initiatives are being posted on SharePoint under Accreditation. These communication summaries are helpful quick hits of information linking the work we do at St. Joseph’s with accreditation standards.

Understanding tracers

When Accreditation Canada surveyors are on-site in October, they will make observations and ask questions to determine if standards are being met. In preparation for these on-site visits, clinical staff who have completed tracer training will be conducting tracers at all sites, providing an opportunity to follow or ‘trace’ the path of a patient or process, similar to an official on-site survey. These tracers allow staff and physicians to practice responding to questions that an accreditation surveyor might ask when they are here in the fall.

Tracers help us to identify our strengths as well as where we have opportunities for quality improvement. Because we know that Accreditation Canada surveyors will be speaking to our patients, families and caregivers while on-site in October, we also have five care partners who have been trained to participate in tracers across the organization which will provide invaluable feedback and learning opportunities for us, from their perspectives. Keep an eye out for leaders, staff and the care partners pictured below, who will be participating in tracers across all programs and departments.

Professional practice consultant, Wendy Robinson, conducts a tracer with Ken Davidson, RN, in the Post-Anesthesia Care Unit at St. Joseph’s Hospital.

“As care partner, I believe it is important to ‘get into the trenches’ as they say, and find out the strengths and weaknesses of the system. Once we know strengths and/or weaknesses, we can deal with them.”

Nancy Davies, Care Partner tracer

St. Joseph’s Care Partners; Vikki, Nancy, Cathie and Kersten participated in a training session to become tracers across St. Joseph’s, helping us to prepare for accreditation this fall.

Lessons from our mock survey

To help us prepare for the on-site survey in October, we arranged for a professional surveyor from Accreditation Canada to visit St. Joseph’s for an in-person mock survey/tracer.

The three-day mock survey occurred this past April and provided a practice opportunity for leaders, staff and physicians to experience having an Accreditation Canada surveyor on-site who asked questions and made observations to determine if standards are being met.

The mock survey provided an opportunity to gain valuable feedback and recommendations, helping us identify strengths as well as where we have opportunities for improvement, and to help us develop work plans in preparation for our on-site survey in October.

The surveyor visited a number of clinical areas and focused on ROPs that were identified through our clinical self-assessment survey.

Overall, the results of our mock survey were very positive. The following suggestions are direct recommendations from the Accreditation Canada surveyor, which highlight the areas of focus we should be leaning into ahead of our on-site survey this fall:

• Ensure patient privac y and confidentialit y is privac conf identiality maintained at all times. I.e.,instead of using a patient’s full name on tracking boards or within any public facing area, use only the first three or four letters of a patient’s last name, or just a first name with a last name initial.

• Review your space or area a ea to ensure that hallways are clutter free and equipment is safely stored. Now is a good time to declutter.

• Review Emergenc y Management Codes and Emergency procedures procedure with your team so that everyone knows their role in an emergency.

• Accreditation sur veyors will be reviewing ‘Quality and Communication Boards’ ‘ ua t y Com unication across the organization. Please ensure your area’s board is updated regularly. Be prepared to provide examples of quality improvements where you/ your team have engaged with patients, residents, family care givers and care partners.

• Ensure regularly audited items/equipment audited are up to date are up to d such as eye wash stations, fridge temperatures, equipment labels etc.

Accreditation Canada surveyor Anita Harris, conducts a mock survey with Elise Pearce, RPN, in the Treatment and Rehabilitation Program at Parkwood Institute Mental Health Care Building.

SPECIAL ACCREDITATION

Refreshed Quality and Communication Boards

Getting to know the refreshed board:

The new headings listed below are rooted in health literacy best practice and were developed based on focus group feedback. Information to include under each section will vary based on program areas:

• Everyday Practices: Things we’re working on every day to be our best - Information in this section highlights monitoring activities that support and/or influence quality and safety.

Shauna Graf, member of St. Joseph’s QSI Team, demonstrates types of content that can be displayed on the refreshed ‘Quality and Communication Boards’.

Early this year, St. Joseph’s Quality Strategy and Innovation (QSI) team initiated a pilot to re-fresh and rename the ‘Quality and Communication Boards’ across our organization. (Previously known as communication boards or huddle boards.)

Since their launch in 2019, these boards have been used as an important tool for communicating quality, safety and risk performance. In addition, they serve as a tool for linking what’s happening on an operational level, back to the priorities within our Corporate Strategic Plan.

In preparation for accreditation, the QSI team was tasked with pulling together a working group and hosting focus groups with staff members and care partners, to look at the board’s design, content and functionality, as well as its effectiveness as a communication tool. The goal of the refresh was to improve staff, physician, patient/resident and family awareness on how we all contribute to excellence in the care provided across St. Joseph’s.

• Opportunities & Improvements: What we’re doing to make the care experience even better - Information in this section highlights initiatives or projects that improve service delivery, quality and/or safety.

• Patients, Residents & Family Caregivers: Important information and how to be a partner in care - Information shared here includes activities or initiatives that directly affects how care is provided or includes patient, resident or family caregiver involvement.

• Kudos and Comments: Have something to share? This section provides opportunity for recognition, positive comments or inspirational thoughts, or other miscellaneous items of interest.

Linking our work back to St. Joseph’s Strategic Plan

To help provide a tangible connection between the pillars of the plan and our everyday work, coloured triangles will be posted on content, indicating where there is a link back to our 2022-2025 Corporate Strategic Plan.

The refreshed quality and communication boards were re-launched in May and are being rolled-out across the organization in phases.

Contact Laura Titus, Specialist, Quality Strategy and Innovation with any questions: Laura.Titus@sjhc.london.on.ca

Our participation in the 2023 Accreditation Canada program demonstrates St. Joseph’s commitment to quality and excellence across all aspects of health care, from patient safety and ethics, to staff training and partnering with the community, so we may provide the very best programs and services to our patients and residents. Our aim is to continue to be recognized for the outstanding commitment to care and safety for our patients.