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.