Accreditation 101
What is "Accreditation?"
Health care accreditation though Accreditation Canada’s Q-mentum program is an ongoing process of assessing health care organizations against standards of excellence to identify what is being done well and what needs to improve (Accreditation Canada, 2016).
Accreditation provides health organizations an independent, third-party assessment of their organization using standards built upon best practices used and validated by similar organizations around the world.
What are the components of the Med Rec Process?
Gold standard is to obtain BPMH and reconciliation through DIS, "NSHA & IWK Ambulatory Medication Reconciliation Report") printed in advance by admin staff for Psychiatry appt
BPMH completed by prescriber after verifying 2 client identifiers at beginning of appointment, reconciles information from DIS, makes changes and resolves any discrepancies.
If client not currently in DIS, then prescribing clinician completed Med Rec using the Best Possible medication History to be completed using the IWK_BEPO form.
Compared to pharmacy records, client and family collateral, medication bottles.
Patient education around medications is part of Med Rec process, allowing for questions, and sharing all relevant information in language that the client/family can understand.
What is required to confirm client ID in a clinic setting?
As per IWK Policy "Patient Identification":
Minimum of 2 person-specific identifiers at any point of care delivery (DOB, full birth name, HCN, K# if confirming against records).
Min 2 identifiers for verifying client in person for care delivery, and in documentation.
What is the Transfer Of Care process in CMHA?
Formal standardized processes include: Policy to guide clinicians across different MHA program "Clinical Handover: Information Transfer at Care Transitions, TOC checklist, TOC checklist SW, Transfer of Care to Adult services - NSHA.
informal: repeat back process, clarifying questions, follow-up emails requesting appropriate information).
The Transfer of Care form promotes clarity and consistency, between care providers, regarding:
What processes are in place to help support staff and client safety in the workspace?
Respectful Workplace policy, signage, LMS module
Confidential Workplace Misconduct Reporting system:
ClearView Connects
P.O. Box 11017
Toronto, Ontario
M1E 1N0
Workplace violence, harassment and bullying assessment and prevention plan (updated q 5 years or more frequently as needed)
JOHSC (Workplace safety inspections, as well as monthly meetings to address safety and work-related concerns)
SIMS follow-ups and Policy "reporting, Management and Quality Review of Pt safety Events" and "Disclosure Patient safety Incidents."
Open door to speak with leadership.
First Aid kits and training on site
NCI training
OHSW policies on workplace violence and harassment (reporting)
PEER support line with OHSW
New YCW / RT community safety SW
Pre-visit Safety screening tool for community and home visits
Patient Safety consultants
What is an "ROP?"
Required Organizational Practices (ROPs) are evidence informed practices addressing high-priority areas that are central to quality and safety. They are defined through guidelines (rationale for ROP) and Tests for Compliance (how we achieve this ROP)
Categorized into 6 major areas:
1. Safety Culture
2. Communication
3. Medication Use
4. Worklife / Workforce
5. Infection Control
6. Risk Assessment
Aside from ROPs, there are other Accreditation Standards that influence the outcome of the Accreditation process.
When is a Med Rec completed?
As per IWK "Medication Reconciliation" policy, med rec for ambulatory settings:
Medication Reconciliation is the responsibility of the most responsible prescriber for the patient. Prescribers should be knowledgeable of, but not responsible for all medications the patient is taking.
The frequency of when medication reconciliation is required (start of care, transitions of care, discharge from service) shall be at the discretion of the clinical team and is related to the timing when patients are seen in the clinics and the frequency at which medications require modification.
What is required to confirm client ID in a community setting? In a virtual setting?
For ambulatory/community visits: At subsequent visits by the same health care provider, the provider may use face-to-face in person recognition, and verification of patient/client’s full name
When is a transfer Of Care Document completed?
At any change in care provider (clinician or team) across IWK MHA services or, other NSH zones, or transfer to adult services (separate document).
Transfers to other services or closing from an IWK service and returned back to GP.
If you or your team has an ethical dilemma, what supports are in place to help address this concern?
Peer support (CTL meeting, colleague consultation, Choice or partnership review times, connect with management for support or direction)
IWK ethics committee: provide consult to teams who are experiencing disagreement over client care, policy.
For all clinical ethics questions contact the Clinical Ethics Committee at 902 470 8053. On Pulse, you can find us by searching ‘Ethics’.
Ethics consultation can take the form of a one-on-one conversation with a member(s) of the Ethics Committees, but more often it involves members of the Clinical Ethics Committee facilitating a discussion for a small or large group.
Members of the Ethics Committees are available to facilitate ethics education sessions, tailored to the relevant unit or program. Topics for ethics education might include: moral distress, informed consent, truth-telling, end of life. In providing education, Committee members may collaborate with other relevant IWK supports.
What is a "Tracer?"
A tracer is the method the Accreditation Canada surveyors use to assess compliance to the accreditation standards by following a patient's care journey or an organizational process.
There are two types of tracers:
1. Clinical
2. Administrative
There are 4 components to a Tracer:
1. Reviewing files and documentation
2. Talking and listening to staff, patients, partners
3. Observing processes, procedures and direct care
4. Recording perceptions and observations
Who gets a Med Rec?
IWK Health care teams have identified which ambulatory care clinics or specific patient types within those groups that have medication management as a major component of care, have a complicated medication regimen or if the patient is at risk for adverse events. Specific criteria for Ambulatory Clinics in each Program are described in Policy 10.30.
How does CMHA share quality improvement initiatives with clients and staff?
CMHA meetings
Biweekly MHA newsletter
TAD
Quality Boards
Name 5 Quality Improvement projects that have occurred in CMHA over the last 4 years
Accessibility:
7 day window for priority for Urgent Choice Appt
7 day window for Priority Partnership
Specific Care EOIs (increase team skill sets)
Option of virtual care team to clients
Trauma Pilot care (Sackville clinicians to expand)
D2
Increase of staff and hours through CR
Halifax clinic reno
RT support, group and 1:1
ANS service
Smudging policy and implementation
Decreased wait times; access initiatives
New YCW / RT community safety SW
What are some ways capacity and skill set are developed within our team?
6-week reviews
Performance reviews
Mandatory and elective LMS modules
Professional Practice meetings
TAD
Weekly team specific meetings
Choice clinic
Choice and Partnership Review
Learning opportunities and funding calls
EOIs
Why do we value Accreditation?
Improves quality and safety of organization through process review, evaluation, and development.
Improves communication and standardization of EBP
Demonstrates IWK's commitment to quality, safety and accountability.
Results in best care for kids and families!
When do we screen for suicide risk?
As per IWK Suicide Risk Assessment, Management and Monitoring policy:
Routine clinical care includes ongoing monitoring, screening and assessment of suicide risk and appropriate documentation at each client/patient contact
A formal SRA will only be conducted on clients/patients with a developmental age of 10 and older, unless otherwise clinically indicated for a younger age
Entry into MHA care (as soon as possible).
Transfer from service area (no need for formal SRA if one has been conducted in the past 24 hours and client/patient condition is assessed as unchanged).
Discharge from care (no need for formal SRA if one has been conducted in the past 24 hours and current suicide risk screening indicates no change in condition.
When possible, SRA is conducted upon discharge even if the most recent screening is low.
When otherwise clinically indicated (such as change in presentation, change in functioning, change in life circumstances, youth going to court).
When relevant, most recent ASARI shared at transfer point between service
How do clients and families partner in their care development and delivery?
Formal feedback (concerns, suggestions, compliments) process: "Anyone, Anytime, Anywhere"
In person to staff (escalated to management)
Email @- feedback@iek.nshealth.ca
phone -1-855-495-2273
yellow cards with QR code at all registration desks
ESQ feedback
SIMS submissions (safety Incident management System)
CAPA partnership model of care
Working with goals support
Choice Clinic
Informed Consent Process
How does CMHA support Falls Prevention?
Identify high risk populations (ie: ED) and assess accordingly (use of falls risk assessment tools).
Environmental supports and assessments: mobility doors, safety rails in washroom, appropriate lighting, non-slip flooring in clinics, staff education at onboarding (universal precautions)
More interventions at in-patient areas (precautions, signage, individual careplans)
How does CMHA handle Personal Health Information of clients?
Staff Confidentiality Pledge at onboarding
LMS module on handling Patient health Information
Secure sharing of information (PCI, MOVEIT it outside of IWK)
Consent to Treatment form
Share on "Need to know basis" only, circle of care
Interacting with Law Enforcement policy
Timely and accurate documentation (SW and policy on Minimum Requirement for Documentation) to ensure information is available for other services (ie: EMHAS).
What might a Surveyor ask me?
· How are patient and families provided with information on their rights and responsibilities?
· How do you report a patient or staff safety incident?
- Do you know who to contact if you have an ethical issue or question that needs to be addressed?
· How does your area/organization promote a healthy workplace?
· What processes are in place to transfer patient information? (e.g., handover or shift reports)
· Tell me about the medication reconciliation process on admission.
· Can you show me your falls prevention approach? What tool(s) are used? How frequently is the assessment completed?
· What changes have been made to improve safety in your area?
· Do you have a policy that outlines the process for disclosure of patient safety incidents? Can you show me a copy?
What is the process of a Risk Assessment?
Screening for suicide risk can be completed by any staff member working in a direct care role with a client/patient as per the IWK Suicide Prevention policy # 1407. If determined (through the suicide risk screening process as outlined in #4 and #5) that a patient/client is at risk for suicide, then a formal suicide risk assessment using the SRA Tool (Form ID IWKASARI), is to be completed by a licensed health care provider
A formal suicide risk assessment can only be completed by the following licensed health care providers: Occupational Therapists, Psychiatrists, Psychiatry Residents, Psychologists, Registered Nurses, and Social Workers.
All licensed health care providers (identified in #1 above) must complete training on the Suicide Risk Assessment Management and Monitoring (SRAMM) Policy and documentation on the Suicide Risk Assessment (SRA) Tool (Form ID IWKASARI).The risk level determined and the level of monitoring and management plan required is documented. Safety plan is to be shared (both verbally and in writing) with those who need the information to promote and maintain the safety of the client/patient.
Routine clinical care includes ongoing monitoring, screening and assessment of suicide risk and appropriate documentation at each client/patient contact.
No specific interventions recommended as risk is felt to be baseline/low. If moderate or high, the immediate risk and the suicide risk safety plan is to be both documented and verbally communicated to:
1.1 The client/patient.
1.2 Parent/legal guardian and/or Substitute Decision Maker (if the client/patient does not have capacity); and
1.3 Members of the circle of care, as appropriate.
Documentation (screening in note, asari with level,outcome/plan) scanned to PCI
How is client feedback followed up in CMHA?
If feedback through feedback line:
The Feedback Coordinator follows the process as outlined in the Patient/Family Feedback Follow-up Process Policy - #331.0. The Feedback Coordinator responds to the feedback provider, acknowledging receipt, and gathers additional information/clarification. The feedback is then forwarded to the most appropriate person, usually a manager, for review and follow up. That person has responsibility to contact the feedback provider directly and to keep them informed of the status of the follow-up process and resolution.
If related to a SIMS event: patient safety rep follow-up with most appropriate person, usually management, who will seek more information from involved staff, client/family directly, coordinate a plan to address concerns and share any changes in practice to larger team through appropriate channels.
Quarterly SIMS reviews to assess safety patterns and address these.
How can staff share safety concerns with MHA leadership?
Direct report to supervisor or manager
SIMS
Feedback line
team meetings
How does data inform our service delivery within CMHA?
Job planning process
Informs posting of positions
Informs strategic planning of services with leadership team
informs priority initiatives and pathways