Hospital services meet national standards
A surgical safety checklist must be completed before every surgery, a safety procedure Niagara Health implemented before new provincial regulations came into effect. The hospital recently earned full accreditation from Accreditation Canada, a designation that fewer than one in three healthcare organizations in Canada receive. Among the patient safety initiatives examined during this process were patient chart reviews and surgical safety checklists.
22 priority areas examined
- Planning & Service Design
- Emergency Preparedness
- Communication
- Integrated Quality Management
- Resource Management
- Human Capital
- Principle-Based Care & Decision-making
- Chronic Disease Management
- Population Health & Wellness
- Patient Flow
- Clinical Leadership
- Competency
- Episode of Care
- Decision Support
- Impact on Outcomes
- Physical Environment
- Medical Devices/Equipment Use
- Medication Management
- Infection Prevention and Control
- Diagnostic Services
- Blood Services
- Surgical Procedures
Tracer Methodology
The healthcare evaluators use a new process called tracer methodology. This new type of examination involves tracing the patient or process and the staff experience, as it happens.
The evaluators ask staff questions about policies and procedures to ensure the patient care process is efficient and timely in and between departments. For example, evaluators may see a patient in Emergency and examine how that department works with Diagnostic Imaging, Lab and Pharmacy to get timely tests and followup. Then, the evaluators follow the patient chart to see that medication reconciliation occurs once the patient is on an inpatient unit.
The quality of programs and services across the Niagara Health System has been evaluated against national standards of excellence and based on the independent review met all of these standards.
Following the exhaustive examination by five healthcare experts earlier this year, Niagara Health is among the top 30% of hospitals in Canada that has been awarded full accreditation by Accreditation Canada.
Similar to ISO 9000 for industry, every few years a team of experts conducts a comprehensive review of hospital programs, processes and documentation, measuring performance against 1,712 different criteria.
“The survey process tells us what we are doing well and where we could improve,” says Frank Demizio, Vice President Patient Services and lead for the accreditation process. “This accreditation award is a result of the hard work and dedication that staff and physicians contribute daily in their roles, as well as in preparing for the survey.”
All aspects of Niagara Health System were reviewed as part of the survey, including programs and services, patient safety, quality improvement, risk management, leadership, plant services and maintenance, infection prevention and control, and medication management. Niagara Health was compliant in more than 95% of the standards and criteria and submitted action plans to address the remaining areas that needed improvement. Shortly after that submission, Accreditation Canada notified the hospital that it met all standards and criteria and is fully accredited until the next review in late 2012.
Accreditation Canada is a not-for-profit, independent organization providing national and international healthcare organizations with an external peer review to assess and improve the services they provide based on standards of excellence.
“Accreditation Canada has approximately 1,060 Canadian clients and only 30% of those clients receive an award of accreditation, so we’re very pleased to have received this award,” Demizio says.
Some of the achievements the surveyors noted include the new hospital and cancer centre development, the framework in which quality measurements are reported, enhanced medication management processes, enhanced infection prevention/control processes and policies, patient safety leadership walkabouts (where leaders meet with front-line staff in their units and discuss patient safety) and strong leadership engagement in financial recovery. Some opportunities for improvement identified include the physical age of Niagara Health infrastructure, implementation of professional staff bylaws, workforce plans and enhancing the patient’s role in patient safety.
“I congratulate our board of trustees, staff and physicians who actively and freely participated in the accreditation process,” says Debbie Sevenpifer, President and CEO. “The value of accreditation is both showcasing the things we do well, and also learning from others as to what we can improve upon. We are firmly committed to continuously improving on quality to ensure our programs and services meet the standards.”
Accreditation Q&A
What does an accreditation award mean for the patients we serve?
Pictured with the accreditation award certificate are, from left, Frank Demizio, Vice President Patient Services; Janice Lesniewski, Charge Nurse, Ontario Street Site Day Surgery and Endoscopy; and Debbie Sevenpifer, President and CEO.
Patients and their families have an expectation that they will receive the best quality care for their condition and one way of providing them with that assurance is having an external peer review. That is Accreditation Canada’s role.
The award validates a wide range of quality and safety components, such as quality, risk management and infection control, just to name a few. The accreditation award verifies that the Niagara Health System has in place an infrastructure and process which provides quality and safe care.
What is the accreditation process?
The accreditation process is a continuous cycle that most hospitals in Canada take part in with Accreditation Canada, a non-profit independent reviewing body. Long before the actual accreditation visit, which occurs every three years, our clinical programs and support services conduct an assessment of their area of focus, getting input from frontline staff, physicians, patients/families and healthcare partners.
The assessment results are then inputted into the Accreditation Canada software, which measures our performance against 1,712 established criteria. The results of the comparison are provided to the programs and services, which then develop action plans for any areas that are flagged as not meeting the requirements of the criteria. Then, evidence is collected and collated, in preparation for the arrival of five expert surveyors on site.
The surveyors are healthcare professionals from across Canada and they tour our sites for several days, examining our patient care processes, as well as Human Resources policies and procedures, information technology systems, governance procedures and a whole host of required organizational practices. These experts then compile their findings, and Accreditation Canada determines whether accreditation will be awarded. A Niagara Health System accreditation steering committee ensures that action plans are implemented for continuous quality improvement.
What were some main findings in the final report?
We have a lot of success stories that the surveyors noted, including the development of the new hospital and cancer centre and an integrated quality reporting framework. One of the main areas where we’ve improved is in better hand hygiene among our staff and physicians. Over the last few years, we’ve struggled with outbreaks on our inpatient units, so we brought in some experts from other hospitals and worked closely with the Ministry of Health and Long-Term Care to roll out the Just Clean Your Hands campaign for staff and physicians. This initiative has really made a difference in preventing the transmission of harmful bacteria. We’ve also increased signage and wall-mounted hand sanitizers so the public has more awareness.
We know we still have a lot to do, particularly in maintaining our aging hospital buildings.
How did Niagara Health earn accreditation in such challenging times?
We engaged as many staff, physicians and volunteers as possible in the process. This engagement included a thorough review and evaluation by our staff and physicians of how the NHS measured up against the standards. The teams and programs received education and support to assist them in the evaluation against the standards and criteria. It is that engagement and a team approach that has allowed us to build on the successes from our last survey. «
