Accreditation Canada Survey
Oct. 15 to 19, 2023
Accreditation Canada surveyors will be visiting St. Joseph’s Health Care London to survey our organization from Oct. 15 to 19. A team of surveyors will be touring each of our main sites and engaging with leaders, staff, physicians, patients/residents, volunteers and care partners to determine how closely our current organizational practices align to Accreditation Canada standards.
While on-site, surveyors may stop and ask you a few questions as you are going about your daily work. To help prepare you for some of the questions that may be asked and what to expect, a sampling of topics have been provided within these pages.
An Internal Publication for St. Joseph’s Health Care London ISSUE 14
Professional practice consultants Tom Kolacyzk (L), and Rebecca Donnelly conducting an internal tracer at Mount Hope Centre for Long Term Care.
ACCREDITATION 2023
Potential Survey Questions
To help prepare for the on-site survey, take a moment to think about how you might answer the following questions:
• How do you receive recognition for your work?
• What education or certification have you received in the past year? (New staff would be asked about orientation training)
• Can you share any information about St. Joseph’s Mission, Vision and Values?
• Tell me about a quality improvement initiative in your area –something you have been a part of that has helped improve care, or the care experience for our patients/residents, your colleagues or family caregivers?
Clinicians and physicians may be asked the following questions:
• How does the team come together to talk about the admission process? How do you involve the patient/resident?
• How does the team come together to discuss the patient or resident and to set goals?
• How would you report a medication error or fall?
• Do you know how to find information about medication errors or falls on your unit and information about changes made?
• Why is medication reconciliation important?
Surveyors will also be observing during their visit, to ensure:
• Medication reconciliation is being conducted.
• Supply carts are properly stored and secured, ensuring no patient/ resident or member of the public has access to needles/sharps, medication or other supplies.
• Areas are free of clutter –drinks and food are stored in appropriate areas.
• Signage is up-to-date and wipeable.
• Quality and Communication Boards are up-to-date across program areas.
• Staff are completing the four moments of hand hygiene.
Surveyors will be interested in the information you provide to patients regarding safety. In addition to sharing patient handbook or safety information in handouts, the surveyor may ask about examples of sharing safety information. Examples may include:
• Please be sure to provide your complete medical history.
• Please bring all your medications to your visit and/or a complete list of medications.
• Please use a single pharmacist to fill your prescriptions.
• Please wash your hands.
• Please tell us if your condition changes while you are with us, or between visits.
• Please let us know if you are at risk of falling.
Key Accreditation Area of Focus
Client and Family-Centred Care
(*NOTE: Client refers to a patient or resident)
Why is there so much focus on patient/resident and familycentred care?
Although client and family-centred care is not considered an ROP, it is one of eight quality dimensions in the Qmentum Quality Framework that underpins all standards.
The focus includes:
• collaborating with patients/residents and their families in planning and service design.
• partnering with them throughout their care.
• engaging them in shared decision making.
• collaborating with them to co-create care plans and health goals.
Patient, resident and family-centred care is an important focus for accreditation and surveyors may ask:
• How do you involve patients/residents/family caregivers in the work you do?
• How does the feedback from patients/residents/family caregivers inform the training or education you receive?
• How do we engage patients/residents/families in quality improvement work?
• What resources do we have to support patients/residents/ family caregivers if they would like to provide feedback or participate in quality improvement activities?
What do we do at St. Joseph’s to engage patients/residents and their caregivers?
There are many ways we receive input and involve our patients/residents and caregivers within our organization:
• Through membership on one of seven patient, resident, family and care partner advisory councils.
• Participation in accreditation tracers and our tracer community of practice.
• Providing input through rounding, surveys and meetings with patients and families.
• Co-designing of new and updated spaces (i.e., St. Joseph’s Hospital cafeteria re-design, Parkwood Institute’s updated Palliative Care unit).
• Collaborating on the creation of patient/family handbooks and other educational materials.
• Involvement in improving our patient safety reporting system.
• Assisting in the development and review of our organizational Family Presence Policy.
• Joining leaders and staff on hiring panels.
• Sharing lived experiences through storytelling.
• Participation in the development of our Corporate Strategic Plan.
• Engagement in research initiatives and internal grant funding reviews.
• Patient and family representatives also participate in quality improvement initiatives across St. Joseph’s (i.e., the creation of care transition binders in the Rehabilitation Program, the Operational Stress Injury Clinic’s program re-design, participation on the Zero Suicide Implementation Committee etc.).
How does St. Joseph’s Care Partnership Office support this area of focus?
• The Care Partnership Office is a dedicated resource that offers ongoing support, connection, consultation, education and leadership for the purposeful engagement of patients, residents, and caregivers throughout St. Joseph’s.
• Through this team, St. Joseph’s leverages the power of lived experience to proactively create meaningful change through the development and sharing of engagement best practices and the embedding of care partnerships at all levels of the organization.
• Staff, leaders and physicians can receive coaching, mentorship and support for engaging with care partners by reaching out to the Care Partnership Office.
• Patients and families can be referred to the Care Partnership Office to take part in any of the opportunities listed in the previous section.
For more information, check out the Care Partnership Office’s page on the intranet for information and resources.
SEPTEMBER 2023
Required Organizational Practices (ROPs)
Accreditation Canada defines a Required Organizational Practice (ROP) as an essential practice that organizations must have in place to enhance patient/resident safety and minimize risk. Accreditation Canada provides compliance tests for all ROPs, and all tests for compliance must be met by the organization to obtain full accreditation status.
ROPs are grouped into six patient safety areas, each with its own goal. Below are examples of ROPs. See the accreditation intranet page to review all ROPs.
ROP: Information Transfer at Care Transitions
Why is this ROP important?
This ROP looks to ensure that the information relevant to a patient’s plan of care is communicated effectively during care transitions. Specifically, when a patient/resident experiences a change to their care team or location (during admission, handover, internal or external transfer and discharge), ensuring the patient/caregiver is aware and the information shared is defined, standardized, documented and has an identified way to audit. This ensures that the right information is shared with the patient’s new clinical staff member or team and minimizes the risk of important information not being passed on.
What are the main things staff need to know?
• Familiarize yourself with the Transfer of Information and Accountability policy and its appendices.
• Familiarize yourself with any program-defined expectations for content and processes related to information transfers.
• Understand that involving the patient/caregiver is essential, and that using standard approaches either before, during or after transfers is effective.
• Information transfers only work if both the sending and receiving staff members actively participate (i.e., ask questions, hold each other accountable for ensuring all the relevant information is shared and documented.)
What might a surveyor ask related to this ROP?
• What do you include in your transfer of information during shift change or to another program?
• How do you involve and inform the patient and family caregivers?
• Where would you document that a transfer of information report was provided?
• Surveyors will also be looking to ensure that the sharing of a patient/resident’s goals is included during transfers. Think about what transfers you are involved in and how you would include sharing the patient’s goals (I.e., at discharge, for next 24 hours, etc.)
? ACCREDITATION 2023
Karen Phillips, personal support worker at Mount Hope (L), participates in an internal tracer with professional practice consultant Rebecca Donnelly.
ROP: Suicide Risk Assessment and Prevention
Why is this ROP important?
Suicide is a global health concern. According to the World Health Organization, more than 800,000 people die by suicide each year. Many of these deaths could be prevented by early recognition of the signs of suicidal thinking and offering appropriate intervention. By screening a patient/resident for suicidal ideation, assessing their level of risk, creating a safety plan and connecting them with the care they need, we can help to prevent the number of deaths by suicide.
What are the main things staff need to know?
• St. Joseph’s implemented the Zero Suicide initiative in 2016 and was awarded a Leading Practice Designation by Accreditation Canada in 2019.
• In all clinical areas, staff have been trained on the use of screening tools, risk formulation and interventions. There are two safety plans in use; one is preventative (Coping Plan) and one is for elevated risk (Suicide Management Plan).
• Staff also have access to triage tools, including a specific mental health tool, a non-mental health tool and virtual care tools, that provide a list of potential interventions based on responses to the Columbia Severity Suicide Rating Scale (C-SSRS) and their overall assessment of risk level.
• Patients at an elevated risk will receive appropriate interventions based on a full assessment and risk formulation.
• All care providers within St. Joseph’s have been made aware of community resources such as CMHA’s mobile crisis team or ‘ReachOut’ program, to whom they can provide a warm hand-off or can seek support and advice.
• Zero Suicide resources are not only for patients, residents, clients and family caregivers, but also for staff, physicians, clinicians, leaders and whomever may need to be connected with support.
What might a surveyor ask, related to this ROP?
• How are patients and residents who may be at-risk of suicide identified?
• If a patient/resident was identified as being at risk, what are some of the first steps you would take?
• Where can you find resources on St. Joseph’s suicide prevention and support services?
• How have patients/residents/ family-caregivers been informed of our Zero Suicide initiative?
Staff and physicians tried their luck with hula-hoops and other fun interactive games to test their knowledge during accreditation fairs held at each site.
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SEPTEMBER 2023
ACCREDITATION 2023
ROP: Client/Patient/Resident Identification
Why is this ROP important?
Working in partnership with patients, residents and families, a minimum of at least two person-specific identifiers are required at St. Joseph’s to confirm that patients/residents receive the service or procedure intended for them. Using person-specific identifiers can avoid harmful incidents such as privacy breaches, allergic reactions, discharge of patients to the wrong families, medication errors and wrong-person procedures.
What are the main things staff need to know?
• Patient identification is done in partnership with patients/residents and families by explaining the reason for this important safety practice and asking them for the identifiers (i.e., “What is your full name?” “What is your date of birth?”) When patients and families are not able to provide this information, other sources of identifiers include wristbands, health records, government-issued identification or registration numbers. In some circumstances, facial recognition can be used as one of the two identifiers.
Staff and physicians enjoyed participating in Accreditation Fairs held at St. Joseph’s sites in June, featuring games and fun ways to test their accreditation knowledge.
• Sometimes an individual may wonder why we are asking them to confirm their name and date of birth, or other appropriate identifiers. If a patient/resident or family caregiver inquires about this, let them know the following: It is our standard practice at St. Joseph’s to ask these questions to help keep you safe. We always want to be confident that the right person is receiving the right care. You, as the patient/ resident/family caregiver are helping us to achieve our safety mandate.
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What might a surveyor ask, related to this ROP?
• How do you know that you have the right patient/resident in front of you when you are providing care?
• If a patient/resident does not have the capacity to confirm their identity verbally, what other ways can you confirm their identity?
• What are the ways in which you confirm the identity of a patient/resident that you may provide care to multiple times a day (i.e., a long-term care or Veteran’s Care resident, or long-stay inpatient)?
What makes you proud to be part of St. Joseph’s?
Across St. Joseph’s, more than 4,800 staff and physicians work alongside one another to support excellence in quality patient care. This fall, Accreditation Canada surveyors will be interested in why our staff choose to work at St. Joseph’s and what keeps them coming back day-after-day.
When you think about what brought you to St. Joseph’s and the work you do, ask yourself these questions:
• Why do you choose to work at and stay at St. Joseph’s?
• What are you most proud of?
St. Joseph’s internal accreditation support team asked these questions of staff and physicians during preparation and engagement events that took place at our main sites this past spring and summer, such as Accreditation Fairs and ice cream and coffee cart sessions. Below is what a few St. Joseph’s colleagues had to share:
“The work that we do is kind of like a symphony. When I think about my role in this department, everything I do is for patient safety and the best patient experience. We are such a critical part of how we keep patients safe and I have so much trust in my team. That is what makes me proud to work for St. Joseph’s. That’s what has kept me here for over 20 years.”
“My leader. She is really there for us and has really supported us through some tough times. She genuinely listens and supports recommendations that we have. This has helped us provide an even better experience for people – and I’m really proud of that.”
“The environment of trust that has been created in our program. I’ve worked in other places where I didn’t feel comfortable to ask questions. Here, it is actually encouraged as the team knows that if we don’t help each other learn, then we are at risk of making mistakes... I know that I can trust and be supported by, my team.”
“My colleagues – they are what keeps me at St. Joseph’s. We are like a family and we support each other both at work and outside of work… we provide great patient care and patients tell us that they have had a great experience at this organization. That makes what we do so worthwhile.”
SEPTEMBER 2023
ACCREDITATION 2023
Thank you for your preparation and support!
A special thank you to St. Joseph’s staff, physicians, leaders, volunteers and care partners for your preparation, engagement and support as we ready ourselves for our 2023 Accreditation Canada Survey.
We know you will earn the complete confidence of surveyors through the incredible work that you do every day and we are grateful for your unwavering commitment to excellence in patient care and quality.
Important information
Additional resources can be found by clicking on the accreditation logo, located on the intranet homepage. If you have questions, please contact your leader or: Jennifer.Payton@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.
SEPTEMBER 2023
Care partner, Cathie Gauthier (bottom right), participating in an accreditation tracer with staff on the Rehabilitation Readiness Unit at Southwest Centre for Forensic Mental Health Care.
“I deeply share the value of St. Joseph’s – that engaging the voices of patients and families is intrinsic to providing good care and the most hopeful future for the whole person; body, mind and spirit.”
Cathie Gauthier, care partner tracer