It’s all about quality improvement

In addition to the daily hustle and bustle of a hospital system with seven sites, this November Niagara Health will undergo an accreditation survey when expert surveyors come to examine hospital practices and processes.

Every three years, healthcare facilities across Canada bring in surveyors from Accreditation Canada for a rigorous examination of programs and services.

Using Accreditation Canada’s new model, NHS staff and physicians have organized into 17 accreditation teams to prepare for the survey. These teams include: Governance/Board; Infection Prevention & Control; Oncology; Critical Care; Maternal Child; Mental Health; Chronic Kidney Disease.

“The hospital accreditation process is a continuous quality improvement program with specific standards to guide us,” says Tracey Davey, Director of Quality and Education and co-ordinator for accreditation. “Surveyors examine hospitals with the following eight dimensions of quality in mind: population focus, accessibility, safety, worklife, client-centred services, continuity of services, effectiveness and efficiency.”

Self Assessment

“In prepping for the site visit, Accreditation Canada provided a series of online questionnaires which were sent out to staff and physicians earlier this year to gauge how we see ourselves and our delivery of programs and services,” Tracey says.

Altogether, 735 staff and physicians filled in these questionnaires, giving their impressions on Niagara Health compliance to Accreditation Canada standards. The answers were collated by Accreditation Canada a few months ago.

“What came back to each of our teams were electronic results showing where we are doing well and in full compliance,” says Tracey. “We also received back areas that were flagged for improvement, and each team is completing action plans to ensure all standards are being met.”

Surveyors will focus questions around 22 priority processes when they come in November and meet with teams, visit departments and units. These broad categories cover the essence of hospital functions and include emergency preparedness, medical devices/equipment use, patient flow and surgical procedures.

The surveyors will visit the clinical units, asking questions and talking to patients and staff to find evidence of quality and safe patient care. They will trace an entire treatment process from start to finish to examine our compliance to standards.

Tracer Methodology

This new type of examination involves the surveyors looking closely at or tracing the patient and staff experience as it happens. The surveyors will talk to staff about policies and procedures to ensure the patient care process is efficient and timely in and between departments.
Surveyors may start with a patient in Emergency and examine how that department works with Diagnostic Imaging, Lab and Pharmacy to provide efficient care for that patient. Then, the surveyors could follow the patient through the admission process to an inpatient unit. While they are tracing the process, they will review Niagara Health’s compliance to standards, priority processes and patient safety practices.

Patient Safety Goals

“In addition to the 22 priority processes covering broad categories such as blood services and competency, a major focus of our survey will be ensuring we are compliant with Accreditation Canada’s Patient Safety Goals and Required Organizational Practices (ROPs),” Tracey says.

“Altogether, there are 31 ROPs to be measured during the survey visit, such as patient safety culture and quarterly reports, patient/client education, patient/client identification, narcotic safety, suicide prevention, infection control guidelines and more.”

“Our teams are working diligently to ensure staff members are fully prepared.” «