Rapport d'accrétidation de la Régie des hôpitaux du Yukon 2014 préparé par Agrément Canada (en...

8/12/2019 Rapport d'accrtidation de la Rgie des hpitaux du Yukon 2014 prpar par Agrment Canada (en anglais)

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Accreditation Report

Yukon Hospital Corporation

On-site survey dates: May 5, 2014 - May 9, 2014

Accredited by ISQua

Whitehorse, YT

Report issued: May 28, 2014


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Confidentiality

This report is confidential and is provided by Accreditation Canada to the organization only. Accreditation Canadadoes not release the report to any other parties.

In the interests of transparency and accountability, Accreditation Canada encourages the organization to

disseminate its Accreditation Report to staff, board members, clients, the community, and other stakeholders.

Any alteration of this Accreditation Report compromises the integrity of the accreditation process and is strictlyprohibited.

About the Accreditation Report

Yukon Hospital Corporation (referred to in this report as the organization) is participating in AccreditationCanada's Qmentum accreditation program. As part of this ongoing process of quality improvement, an on-site

survey was conducted in May 2014. Information from the on-site survey as well as other data obtained from theorganization were used to produce this Accreditation Report.

Accreditation results are based on information provided by the organization. Accreditation Canada relies on theaccuracy of this information to plan and conduct the on-site survey and produce the Accreditation Report.

QMENTUM PROGRAM

Accreditation Canada, 2014


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A Message from Accreditation Canada's President and CEO

On behalf of Accreditation Canada's board and staff, I extend my sincerest congratulations to your board, yourleadership team, and everyone at your organization on your participation in the Qmentum accreditation program.

Qmentum is designed to integrate with your quality improvement program. By using Qmentum to support andenable your quality improvement activities, its full value is realized.

This Accreditation Report includes your accreditation decision, the final results from your recent on-site survey,and the instrument data that your organization has submitted. Please use the information in this report and inyour online Quality Performance Roadmap to guide your quality improvement activities.

Your Accreditation Specialist is available if you have questions or need guidance.

Thank you for your leadership and for demonstrating your ongoing commitment to quality by integratingaccreditation into your improvement program. We welcome your feedback about how we can continue tostrengthen the program to ensure it remains relevant to you and your services.

We look forward to our continued partnership.

Sincerely,

Wendy NicklinPresident and Chief Executive Officer

QMENTUM PROGRAM

A Message from Accreditation Canada's President and CEO


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4.0 Instrument Results 67

4.1 Governance Functioning Tool 67

4.2 Patient Safety Culture Tool 71

4.3 Worklife Pulse 73

4.4 Client Experience Tool 75

5.0 Organization's Commentary 76

Appendix A Qmentum 7

Appendix B Priority Processes 7

QMENTUM PROGRAM

iiTable of ContentsAccreditation Report


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Yukon Hospital Corporation (referred to in this report as the organization) is participating in AccreditationCanada's Qmentum accreditation program. Accreditation Canada is an independent, not-for-profit organization

that sets standards for quality and safety in health care and accredits health organizations in Canada and aroundthe world.

As part of the Qmentum accreditation program, the organization has undergone a rigorous evaluation process.Following a comprehensive self-assessment, external peer surveyors conducted an on-site survey during whichthey assessed this organization's leadership, governance, clinical programs and services against AccreditationCanada requirements for quality and safety. These requirements include national standards of excellence;required safety practices to reduce potential harm; and questionnaires to assess the work environment, patientsafety culture, governance functioning and client experience. Results from all of these components are includedin this report and were considered in the accreditation decision.

This report shows the results to date and is provided to guide the organization as it continues to incorporate theprinciples of accreditation and quality improvement into its programs, policies, and practices.

The organization is commended on its commitment to using accreditation to improve the quality and safety of theservices it offers to its clients and its community.

1.1 Accreditation Decision

Yukon Hospital Corporation's accreditation decision is:

Accredited (Report)

The organization has succeeded in meeting the fundamental requirements of the accreditation program.

QMENTUM PROGRAM

Executive SummarySection 1

Executive Summary 1Accreditation Report


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QMENTUM PROGRAM

1.2 About the On-site Survey

On-site survey dates: May 5, 2014 to May 9, 2014

Locations

The following locations were assessed during the on-site survey. All sites and services offered by theorganization are deemed accredited.

1 Watson Lake Hospital

2 Whitehorse General Hospital

Standards

The following sets of standards were used to assess the organization's programs and services during theon-site survey.

System-Wide Standards

Leadership1

Governance2

Medication Management Standards3

Service Excellence Standards

Operating Rooms4

Surgical Care Services5

Emergency Department6

Diagnostic Imaging Services7

Medicine Services8

Ambulatory Systemic Cancer Therapy Services9

Obstetrics Services10

Mental Health Services11

Biomedical Laboratory Services12

Infection Prevention and Control13

Reprocessing and Sterilization of Reusable Medical Devices14



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QMENTUM PROGRAM

Instruments

The organization administer:

Governance Functioning Tool1

Patient Safety Culture Tool2

Worklife Pulse Tool3

Client Experience Tool4



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QMENTUM PROGRAM

1.3 Overview by Quality Dimensions

Accreditation Canada defines quality in health care using eight dimensions that represent key service elements.Each criterion in the standards is associated with a quality dimension. This table shows the number of criteriarelated to each dimension that were rated as met, unmet, or not applicable.

Quality Dimension Met Unmet N/A Total

Population Focus (Working with communities toanticipate and meet needs) 45 9 0 54

Accessibility (Providing timely and equitableservices) 70 6 0 76

Safety (Keeping people safe) 429 69 18 516

Worklife (Supporting wellness in the workenvironment) 116 15 0 131

Client-centred Services (Putting clients andfamilies first) 126 10 2 138

Continuity of Services (Experiencing coordinatedand seamless services) 46 0 0 46

Effectiveness (Doing the right thing to achieve thebest possible results) 594 88 26 708

Efficiency (Making the best use of resources)52 4 1 57

Total 1478 201 47 1726



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QMENTUM PROGRAM

1.4 Overview by Standards

The Qmentum standards identify policies and practices that contribute to high quality, safe, and effectivelymanaged care. Each standard has associated criteria that are used to measure the organization's compliance withthe standard.

System-wide standards address quality and safety at the organizational level in areas such as governance andleadership. Population-specific and service excellence standards address specific populations, sectors, andservices. The standards used to assess an organization's programs are based on the type of services it provides.

This table shows the sets of standards used to evaluate the organization's programs and services, and the numberand percentage of criteria that were rated met, unmet, or not applicable during the on-site survey.

Accreditation decisions are based on compliance with standards. Percent compliance is calculated to the decimaland not rounded.

Standards SetMet Unmet N/A

High Priority Criteria *

# (%) # (%) #

Met Unmet N/A

Other Criteria

# (%) # (%) #

Met Unmet N/A

Total Criteria(High Priority + Other)

# (%) # (%) #

Governance 40(90.9%)

4(9.1%)

0 31(91.2%)

3(8.8%)

0 71(91.0%)

7(9.0%)

0

Leadership 43(93.5%)

3(6.5%)

0 76(89.4%)

9(10.6%)

0 119(90.8%)

12(9.2%)

0

MedicationManagementStandards

58(79.5%)

15(20.5%)

5 50(84.7%)

9(15.3%)

5 108(81.8%)

24(18.2%)

10

Infection Preventionand Control

45(90.0%)

5(10.0%)

3 36(83.7%)

7(16.3%)

1 81(87.1%)

12(12.9%)

4

Ambulatory SystemicCancer TherapyServices

35(85.4%)

6(14.6%)

5 86(87.8%)

12(12.2%)

0 121(87.1%)

18(12.9%)

5

Biomedical LaboratoryServices

60(92.3%)

5(7.7%)

4 85(88.5%)

11(11.5%)

2 145(90.1%)

16(9.9%)

6

Diagnostic Imaging

Services

61

(93.8%)

4

(6.2%)

2 58

(96.7%)

2

(3.3%)

1 119

(95.2%)

6

(4.8%)

3

EmergencyDepartment

31(100.0%)

0(0.0%)

0 78(90.7%)

8(9.3%)

9 109(93.2%)

8(6.8%)

9

Medicine Services 23(88.5%)

3(11.5%)

1 63(91.3%)

6(8.7%)

0 86(90.5%)

9(9.5%)

1



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QMENTUM PROGRAM

Standards SetMet Unmet N/A

High Priority Criteria *

# (%) # (%) #

Met Unmet N/A

Other Criteria

# (%) # (%) #

Met Unmet N/A

Total Criteria(High Priority + Other)

# (%) # (%) #

Mental Health Services 30(96.8%)

1(3.2%)

1 81(92.0%)

7(8.0%)

0 111(93.3%)

8(6.7%)

1

Obstetrics Services 59(96.7%)

2(3.3%)

2 70(93.3%)

5(6.7%)

0 129(94.9%)

7(5.1%)

2

Operating Rooms 62(91.2%)

6(8.8%)

1 26(86.7%)

4(13.3%)

0 88(89.8%)

10(10.2%)

1

Reprocessing andSterilization ofReusable MedicalDevices

31(83.8%) 6(16.2%) 3 39(68.4%) 18(31.6%) 2 70(74.5%) 24(25.5%) 5

Surgical Care Services 25(83.3%)

5(16.7%)

0 53(81.5%)

12(18.5%)

0 78(82.1%)

17(17.9%)

0

603(90.3%)

65(9.7%)

27 832(88.0%)

113(12.0%)

20 1435(89.0%)

178(11.0%)

47Total

* Does not includes ROP (Required Organizational Practices)



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1.5 Overview by Required Organizational Practices

A Required Organizational Practice (ROP) is an essential practice that an organization must have in place toenhance client safety and minimize risk. Each ROP has associated tests for compliance, categorized as major andminor. All tests for compliance must be met for the ROP as a whole to be rated as met.

This table shows the ratings of the applicable ROPs.

Required Organizational Practice Overall rating Test for Compliance Rating

Major Met Minor Met

Patient Safety Goal Area: Safety Culture

Adverse Events Disclosure(Leadership)

Met 3 of 3 0 of 0

Adverse Events Reporting(Leadership)

Met 1 of 1 1 of 1

Client Safety Quarterly Reports(Leadership)

Unmet 1 of 1 0 of 2

Client Safety Related Prospective Analysis(Leadership)

Met 1 of 1 1 of 1

Patient Safety Goal Area: Communication

Client And Family Role In Safety(Ambulatory Systemic Cancer TherapyServices)

Unmet 0 of 2 0 of 0

Client And Family Role In Safety(Diagnostic Imaging Services)

Met 2 of 2 0 of 0

Client And Family Role In Safety(Medicine Services)

Unmet 0 of 2 0 of 0

Client And Family Role In Safety(Mental Health Services)

Met 2 of 2 0 of 0

Client And Family Role In Safety(Obstetrics Services)

Met 2 of 2 0 of 0

Client And Family Role In Safety(Surgical Care Services)

Met 2 of 2 0 of 0



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Major Met Minor Met


Dangerous Abbreviations(Medication Management Standards)

Met 4 of 4 3 of 3

Information Transfer(Ambulatory Systemic Cancer TherapyServices)

Met 2 of 2 0 of 0

Information Transfer(Emergency Department)

Met 2 of 2 0 of 0

Information Transfer(Medicine Services)

Met 2 of 2 0 of 0

Information Transfer(Mental Health Services)

Met 2 of 2 0 of 0

Information Transfer(Obstetrics Services)

Met 2 of 2 0 of 0

Information Transfer(Surgical Care Services)

Met 2 of 2 0 of 0

Medication reconciliation as a strategic

priority(Leadership)

Met 4 of 4 2 of 2

Medication reconciliation at caretransitions(Ambulatory Systemic Cancer TherapyServices)

Unmet 1 of 7 0 of 0

Medication reconciliation at caretransitions(Emergency Department)

Met 5 of 5 0 of 0

Medication reconciliation at care

transitions(Medicine Services)

Met 5 of 5 0 of 0

Medication reconciliation at caretransitions(Mental Health Services)

Met 5 of 5 0 of 0



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QMENTUM PROGRAM


Major Met Minor Met


Medication reconciliation at caretransitions(Obstetrics Services)

Met 5 of 5 0 of 0

Medication reconciliation at caretransitions(Surgical Care Services)

Met 5 of 5 0 of 0

Safe Surgery Checklist

(Obstetrics Services)

Met 3 of 3 2 of 2

Safe Surgery Checklist(Operating Rooms)

Met 3 of 3 2 of 2

Two Client Identifiers(Ambulatory Systemic Cancer TherapyServices)

Unmet 0 of 1 0 of 0

Two Client Identifiers(Biomedical Laboratory Services)

Unmet 0 of 1 0 of 0

Two Client Identifiers(Diagnostic Imaging Services)

Met 1 of 1 0 of 0

Two Client Identifiers(Emergency Department)

Met 1 of 1 0 of 0

Two Client Identifiers(Medicine Services)

Met 1 of 1 0 of 0

Two Client Identifiers(Mental Health Services)

Met 1 of 1 0 of 0

Two Client Identifiers(Obstetrics Services)

Met 1 of 1 0 of 0

Two Client Identifiers(Operating Rooms) Met 1 of 1 0 of 0

Two Client Identifiers(Surgical Care Services)

Met 1 of 1 0 of 0



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Major Met Minor Met

Patient Safety Goal Area: Medication Use

Antimicrobial Stewardship(Medication Management Standards)

Unmet 0 of 4 0 of 1

Concentrated Electrolytes(Medication Management Standards)

Unmet 0 of 3 0 of 0

Heparin Safety(Medication Management Standards)

Met 4 of 4 0 of 0

High-Alert Medications(Medication Management Standards)

Unmet 3 of 5 2 of 3

Infusion Pumps Training(Ambulatory Systemic Cancer TherapyServices)

Met 1 of 1 0 of 0

Infusion Pumps Training(Emergency Department)

Met 1 of 1 0 of 0

Infusion Pumps Training(Medicine Services)

Unmet 0 of 1 0 of 0

Infusion Pumps Training

(Mental Health Services)

Unmet 0 of 1 0 of 0

Infusion Pumps Training(Obstetrics Services)

Unmet 0 of 1 0 of 0

Infusion Pumps Training(Operating Rooms)

Unmet 0 of 1 0 of 0

Infusion Pumps Training(Surgical Care Services)

Unmet 0 of 1 0 of 0

Narcotics Safety(Medication Management Standards)

Met 3 of 3 0 of 0

Patient Safety Goal Area: Worklife/Workforce

Client Safety Plan(Leadership)

Met 2 of 2 2 of 2

Client Safety: Education And Training(Leadership)

Unmet 0 of 1 0 of 0



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Major Met Minor Met


Preventive Maintenance Program(Leadership)

Unmet 3 of 3 0 of 1

Workplace Violence Prevention(Leadership)

Met 5 of 5 3 of 3

Patient Safety Goal Area: Infection Control

Hand-Hygiene Compliance

(Infection Prevention and Control)

Unmet 0 of 1 0 of 2

Hand-Hygiene Education and Training(Infection Prevention and Control)

Met 2 of 2 0 of 0

Infection Rates(Infection Prevention and Control)

Unmet 1 of 1 2 of 3

Reprocessing(Infection Prevention and Control)

Met 1 of 1 1 of 1

Patient Safety Goal Area: Falls Prevention

Falls Prevention Strategy

(Ambulatory Systemic Cancer TherapyServices)

Unmet 0 of 3 0 of 2

Falls Prevention Strategy(Diagnostic Imaging Services)

Unmet 3 of 3 0 of 2

Falls Prevention Strategy(Medicine Services)

Met 3 of 3 2 of 2

Falls Prevention Strategy(Mental Health Services)

Met 3 of 3 2 of 2

Falls Prevention Strategy

(Obstetrics Services)

Unmet 3 of 3 0 of 2

Falls Prevention Strategy(Surgical Care Services)

Met 3 of 3 2 of 2



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Major Met Minor Met

Patient Safety Goal Area: Risk Assessment

Pressure Ulcer Prevention(Medicine Services)

Met 3 of 3 2 of 2

Pressure Ulcer Prevention(Surgical Care Services)

Unmet 3 of 3 1 of 2

Suicide Prevention(Mental Health Services)

Unmet 4 of 5 0 of 0

Venous Thromboembolism Prophylaxis(Medicine Services)

Met 3 of 3 2 of 2

Venous Thromboembolism Prophylaxis(Surgical Care Services)

Met 3 of 3 2 of 2



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The surveyor team made the following observations about the organization's overall strengths,opportunities for improvement, and challenges.

1.6 Summary of Surveyor Team Observations

The organization, Yukon Hospital Corporation (YHC) is commended on preparing for and participating in theQmentum survey program. The organization currently operates three hospitals within the Yukon namely:Whitehorse General Hospital (WGH), Watson Lake Community Hospital (WLCH) and Dawson City CommunityHospital (DCCH). During this 2014 accreditation survey the hospitals in Whitehorse and in Watson Lake werevisited. Services at Dawson City Community Hospital were not all fully operational at the time of the visit.

The past three years has been a time of significant growth and building for the organization. Since the 2011survey the WLCH and DCCH have been constructed and opened and have joined the YHC corporation. Theplanning, design and approval phases for new magnetic resonance imaging (MRI) equipment and installation hasbeen completed, and the WGH expansion project is in the planning phase. The Thomson Centre, attached to

WGH, has been renovated and opened with twenty-nine continuing care beds. Although the service is operatedby the Department of Health and Social Services via Continuing Care, the YHC supports the facility by providingmaintenance, food and linen services and security in a lease-tenant arrangement.

Also since the previous survey, the 32 unit residence facility that houses students, locums and staff members andis located on the WGH campus site has been constructed and opened. This building also houses a day care andleased office space for government offices. Although there are still plans and work underway for an expansion atthe WGH site, it is time for the organization to consolidate its gains and move forward in operational andprogramming areas that were suspended while time and effort was directed to these projects. It is also time tofully integrate the clinical services delivery policies and procedures between the three hospitals to ensureconsistently high-quality care across the corporations hospital system.

The organization has been active in addressing some of the gaps identified in the report recommendations fromthe previous 2011 survey of Whitehorse General Hospital (WGH) and the 2012 Primer survey for Watson LakeCommunity Hospital (WLCH). A new performance evaluation program (PEP) is being rolled out at the time of this2014 survey. It aligns with the strategic priorities of the organization with respect to position accountabilities.An occupational health and safety (OHS) audit was completed and implementation of the action plan is underway. The information technology (IT) and systems department has undertaken many new projects to support theorganization both for the WGH site and for its community hospitals, including the introduction of wirelesstechnology at WGH to support the strategic direction for enhancing the patient experience. The department alsosupports the electronic system that interfaces with hospital laboratory, diagnostic imaging and otherreport-generating departments, with 80% of physician offices in the community now online. There are plans toimplement the physician order functionality in this system.

The organizations facilities continue to be clean and well maintained. The new community hospital in WatsonLake is spacious and welcoming. The organization is commended for the progress on emergency preparedness.Noteworthy are the policies and procedures related to the various emergency codes, evolution of the use of the

incident command system (ICS) and most recently, the extensive mass casualty exercises conducted inWhitehorse and Watson Lake with federal (former) and regional partners. The organization is encouraged toensure that lessons learned from these exercises are acted on and incorporated into quality improvementinitiatives. System processes have been introduced to assist with the standardization, handling/ tracking/approval and evaluation of business case plans. The soon-to-be launched strategic and financial annual planningcalendar will also help clarify expectations and time lines for the executive/ director/manager group. The repairand preventive maintenance tracking and documentation is now done via the electronic ARCHIBUS system, andthere are clear processes for tracking fixed assets and capital equipment.



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The organization is commended for the noted strengths with inter-professional collaboration among the

pharmacists, physicians and nurses. During the on-site survey this was most effectively demonstrated regardingthe excellent commitment and adoption of a collaborative model of medication reconciliation for admission,transfer and discharge. The organization is also commended for its comprehensive high-alert medication policyand procedures as this will enable proactive identification and prevention of potential errors. The organization isencouraged to ensure that the policy is consistently applied in all practice areas such as for chemotherapy, andsites such as at Watson Lake. There is a noted concern regarding the lack of an intravenous (IV) admixtureservice for preparing IV medications. Specifically, this concerns the high-risk/high-alert medications and need toprepare them in an area that complies with best practice medication safety standards for the preparation of IVadmixtures. The organization is encouraged to give priority to developing an IV admixture service to address safepreparation of IV admixtures. The use of medication automation as a consideration for tracking and use in theadministration of high-risk medications such as narcotics and controlled drug substances is recommended forimplementation in the pharmacy, as well as in the emergency department and in the operating room.

The organization is commended for its recruitment of clinical pharmacists that have commitment and dedication

toward optimizing safe patient medication management and using a collaborative approach withinter-professional team members. The re-organization and re-structuring of Yukon Hospital Corporation (YHC) atthe senior executive level to reflect the strategic priorities of the organization is a work in progress. Theorganization is adjusting to this new administrative structure as well as to the integration of the two communityhospital facilities. The organization is encouraged to consider the participation of the chief of staff in executiveteam meetings to assist with medical and clinical input to planning and decision-making.

The integrated quality management model provides an excellent framework for identifying all aspects of quality,safety and risk. It is up to the organization to re-affirm or modify its quality and safety plan. From there, theorganization needs to decide how it will make the quality and safety plan operational and what supports andstructures will be needed to successfully implement, monitor and evaluate that plan. The project managementand business case approach is a valuable tool for use in quality and safety initiatives, clarifying keyaccountabilities and deliverables. At the same time, an integrated quality plan for the organization must take

into account: day-to-day operational quality and safety activities such as how and what education is delivered;how change is managed; a process for developing and approving policy and procedures; occupational health andsafety; infection prevention and control and the supports needed for the regular maintenance of quality andsafety programs.

The organization is encouraged to consider how best to bring the patient/client voice to the table. There are anumber of good models used in Canada where patient engagement and partnerships are used to advance thequality agenda. The proposed work at YHC to implement a new survey tool to measure patient satisfaction andengagement will contribute well to the organizations quality journey.

The Secure Medical Unit is commended for the work it has done to promote and encourage interdisciplinarycare. The care plans and Kardex format support this client-centred approach to care. Unit staff members havereached out to community partners and the new multi-agency committee aimed at improving quality for clientswill enhance collaboration and coordination of care between the key health care provider organizations.

The organization needs to further clarify pharmacy and laboratory and diagnostic imaging professional leadershipaccountabilities in the community hospitals. Staff members across the organization need to understand the linesof communication and authority within the new organizational structure as it relates to their work. In healthcare organizations there is often a matrix structure required to ensure there is integration and coordinatedactivity. Also needed is aligning clinical accountability of program or discipline-specific leadership whileretaining operational accountability with local managers. In some organizations this coordination andcollaboration occurs via a committee structure and in others it occurs in a less formal way with the expectations


of position roles and responsibilities and support of content experts that support integration activities.


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Currently, the Board of Trustees, which is the governing body for the organization, is nearing the end of its ownwork to review and affirm/develop governing policies and procedures, sub-committee terms of reference and

other items that will guide its work. Board members have access to the Sharepoint internet-based system wherethey can find the governance guide, reference library and organizational policies and procedures. The boardclearly understands it is a governing board and the board chair voiced the boards commitment to quality andsafety and the strategic plan.

Community partners acknowledge the importance of the YHC in the community and in the Territory. Theyappreciate the beginning efforts to partner with YHC on patient-related and non-patient related initiatives andwould like further opportunities to communicate and work together. It is suggested the YHC or the YHCFoundation consider developing a volunteer program. There are opportunities to be realized with respect to avolunteer-run gift shop, patient visitation and socialization. In addition, a junior volunteer program wouldfamiliarize young people with professions and opportunities in health care.

The organization is experiencing some challenges with acute inpatient beds being taken up by patients requiringan alternate level of care (ALC) placement. There are examples where surgeries have been cancelled due to

unavailability of beds and where patients have stayed overnight in the emergency department waiting for aninpatient bed. An organizational culture of safety was evidenced in several areas that were visited during thesurvey despite the relatively poor results of the Patient Safety Tool where staff rated patient safety as poor. Theclient safety plan and staff attention to safety in specific clinical and support areas is good, although there isevidence that not all staff members had received annual staff training. The organization supports staffeducation and offers a variety of mandatory and non-mandatory education programs, certifications andin-services. There was evidence however, that mandatory education is not being completed despite efforts bythe organization to hold multiple sessions and offer it in a variety of ways. The risk of employees not completingeducation deemed mandatory for safe performance of their role and responsibility poses a significant risk to theorganization. It also poses a risk to the professionals license to practice. An electronic learning managementsystem (LMS) is being implemented for education appropriate to this form of delivery. Thus far, workplacehazardous management information system (WHMIS) and hand hygiene instruction are delivered using the LMS.The Patient Services department is also looking at building education in to the regular staff schedule. The

organization is strongly encouraged to look at ways to ensure compliance in this area. Also, the organization isencouraged to consider orientation and the implementation of a mentoring system for new graduates,particularly in the nursing area. Past experience by the organization has shown that nurses receiving severalmonths of orientation and mentoring leads to long-term employees and better retention of staff.

The organization is encouraged to develop a process for policy and procedure development and approval and toclarify accountabilities in this area. Ideally, the process would have a policy review component, fast track policydevelopment and approval process when required and guidelines to help staff write policies. The process wouldalso ensure that there is alignment between the approval authority for polices and the operational responsibilityfor implementing policies. Many policies are being reviewed and at this time and there is a mix of updated andoutdated policies on Sharepoint, some with references that are twenty years old.

Organization inertia in the face of rapid change is not unusual and an understanding of change management isessential for leaders that are spearheading changes. Engagement with physicians and staff members requires

board support and dialogue, along with a clear mandate for quality and safety, perseverance on issues importantto the organization that impact patient and staff safety and attention to concerns that matter to staff andphysicians. Meaningful change at the point where care or support is being delivered occurs when those involvedare part of the change process and own the change.



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Detailed Required Organizational Practices ResultsSection 2

Each ROP is associated with one of the following patient safety goal areas: safety culture, communication,medication use, worklife/workforce, infection control, or risk assessment.

This table shows each unmet ROP, the associated patient safety goal, and the set of standards where it appears.

Unmet Required Organizational Practice Standards Set

Patient Safety Goal Area: Safety Culture

Leadership 15.11Client Safety Quarterly ReportsThe organization's leaders provide the governing body withquarterly reports on client safety, and includerecommendations arising out of adverse incidentinvestigation and follow-up, and improvements made.


Medicine Services 15.4 Ambulatory Systemic Cancer TherapyServices 21.5

Client And Family Role In SafetyThe team informs and educates clients and families inwriting and verbally about the client and family's role inpromoting safety.

Ambulatory Systemic Cancer TherapyServices 15.5 Biomedical Laboratory Services 19.2

Two Client IdentifiersThe team uses at least two client identifiers beforeproviding any service or procedure.

Ambulatory Systemic Cancer TherapyServices 9.15

Medication reconciliation at care transitionsWith the involvement of the client, family, or caregiver (asappropriate), the team generates a Best PossibleMedication History (BPMH) and uses it to reconcile clientmedications at ambulatory care visits where the client is atrisk of potential adverse drug events*. Organizationalpolicy determines which type of ambulatory care visitsrequire medication reconciliation, and the how oftenmedication reconciliation is repeated. *Ambulatory careclients are at risk of potential adverse drug events whentheir care is highly dependent on medication managementOR the medications typically used are known to be

associated with potential adverse drug events (based onavailable literature and internal data).

Detailed Required Organizational Practices Results 16Accreditation Report


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Patient Safety Goal Area: Medication Use

Medication Management Standards 12.9Concentrated ElectrolytesThe organization evaluates and limits the availability ofconcentrated electrolytes to ensure that formats with thepotential to cause harmful medication incidents are notstocked in client service areas.

Operating Rooms 2.3 Surgical Care Services 4.4 Medicine Services 4.4 Mental Health Services 4.4

Obstetrics Services 4.5

Infusion Pumps TrainingThe team receives ongoing, effective training on allinfusion pumps for staff and service providers.

Medication Management Standards 2.3Antimicrobial StewardshipThe organization has a program for antimicrobialstewardship to optimize antimicrobial use. Note:Beginning in January 2013, this ROP will only apply toorganizations that provide inpatient acute care services.For organizations that provide inpatient cancer, inpatientrehab, and complex continuing care services, evaluation ofthis ROP will begin in January 2014.

Medication Management Standards 2.5High-Alert MedicationsThe organization implements a comprehensive strategy forthe management of high-alert medications.


Leadership 10.8Client Safety: Education And TrainingThe organization delivers client safety training andeducation at least annually to the organization's leaders,staff, service providers, and volunteers, includingeducation targeted to specific client safety focus areas.

Leadership 9.7Preventive Maintenance Program

The organization's leaders implement an effectivepreventive maintenance program for medical devices,medical equipment, and medical technology.



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Patient Safety Goal Area: Infection Control

Infection Prevention and Control 1.2Infection RatesThe organization tracks infection rates; analyzes theinformation to identify clusters, outbreaks, and trends;and shares this information throughout the organization.

Infection Prevention and Control 6.5Hand-Hygiene ComplianceThe organization evaluates its compliance with acceptedhand-hygiene practices.

Patient Safety Goal Area: Falls Prevention

Diagnostic Imaging Services 15.6 Obstetrics Services 18.2 Ambulatory Systemic Cancer TherapyServices 21.2

Falls Prevention StrategyThe team implements and evaluates a falls preventionstrategy to minimize client injury from falls.

Patient Safety Goal Area: Risk Assessment

Surgical Care Services 7.9Pressure Ulcer PreventionThe team assesses each client's risk for developing apressure ulcer and implements interventions to preventpressure ulcer development.

Mental Health Services 7.5Suicide PreventionThe team assesses and monitors clients for risk of suicide.



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Detailed On-site Survey ResultsSection 3

This section provides the detailed results of the on-site survey. When reviewing these results, it is important toreview the service excellence and the system-wide results together, as they are complementary. Results are

presented in two ways: first by priority process and then by standards sets.

Accreditation Canada defines priority processes as critical areas and systems that have a significant impact on thequality and safety of care and services. Priority processes provide a different perspective from that offered bythe standards, organizing the results into themes that cut across departments, services, and teams.

For instance, the patient flow priority process includes criteria from a number of sets of standards that addressvarious aspects of patient flow, from preventing infections to providing timely diagnostic or surgical services. Thisprovides a comprehensive picture of how patients move through the organization and how services are deliveredto them, regardless of the department they are in or the specific services they receive.

During the on-site survey, surveyors rate compliance with the criteria, provide a rationale for their rating, andcomment on each priority process.

Priority process comments are shown in this report. The rationale for unmet criteria can be found in theorganization's online Quality Performance Roadmap.

See Appendix B for a list of priority processes.

ROP Required Organizational Practice

High priority criterion

INTERPRETING THE TABLES IN THIS SECTION: The tables show all unmet criteria from each set ofstandards, identify high priority criteria (which include ROPs), and list surveyor comments related toeach priority process.

High priority criteria and ROP tests for compliance are identified by the following symbols:

Major ROP Test for Compliance

Minor ROP Test for Compliance

MAJOR

MINOR

Detailed On-site Survey Results 19Accreditation Report


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3.1 Priority Process Results for System-wide Standards

The results in this section are presented first by priority process and then by standards set.

Some priority processes in this section also apply to the service excellence standards. Results of unmet criteriathat also relate to services should be shared with the relevant team.

3.1.1 Priority Process: Planning and Service Design

Developing and implementing infrastructure, programs, and services to meet the needs of the populations andcommunities served

Unmet Criteria High PriorityCriteria

Standards Set: Leadership

The organization's leaders develop and implement a process to managechange.

6.5



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when client and staff safety is at risk.


Surveyor comments on the priority process(es)

The organization reviewed its mission, vision and values statements in 2012, and these are communicated viathe website, annual report and the strategic plan. Governance, senior leadership, staff members and avariety of stakeholders were consulted during the development of the strategic plan for 2013-2017. Onecommunity partner confirmed their organization had received a letter from the chief executive office (CEO)inviting their participation in providing input to the plan. Although the organization had not received furtherfeedback on the strategic plan it had been pleased to have received the letter asking for input. Theorganization is encouraged to follow up with community partners regarding providing information on thestrategic plan, with emphasis on the four strategic priorities, one of which is the enhancement of communitypartnerships.

During the on-site survey community partners indicated the need for an in-patient mental health facility, anda desire to share information on emergency medical services (EMS) calls for the purpose of developing

education for EMS personnel around the most common calls. Partners also commented on the gap that existsbecause there is no volunteer program in place. Discharge planning was identified as an area where morework could be done, especially in collaboration with the First Nations Health Program. A rapid Home Careresponse to the emergency (ER) department was also confirmed as a worthwhile joint initiative that mightassist with the alternate level of care (ALC) problem.

The organization has been very busy in planning and designing new and expanded services. Decisions areinformed by data from numerous sources and reflect the needs that will occur with the future growth inpopulation and in specific age-groups. Much effort and time has been expended by operational managers. Theuse of a project management approach, documented decision-making and the collaboration of allstakeholders has been instrumental in increasing the effectiveness and efficiency of planning.

The change processes the organization uses should be reviewed to identify where improvements can bemade. Addressing barriers to change will help the organization make some of the necessary changes required


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3.1.2 Priority Process: Governance

Meeting the demands for excellence in governance practice.


Standards Set: Governance

Each member of the governing body signs a statement acknowledging his orher role and responsibilities, including expectations of the position andlegal duties.

2.6

The governing body uses the ethics framework and evidence-informedcriteria to guide decision making.

3.1

The governing body has a succession plan for the CEO.7.8

The governing body works with the CEO to establish, implement, andevaluate a communication plan for the organization.

10.3

The communication plan includes strategies to communicate key messagesto staff, stakeholders, and the community.

10.4

The governing body follows a process to regularly evaluate its performanceand effectiveness.

13.4

The governing body regularly evaluates the performance of the board chairbased on established criteria.

13.6


The Yukon Hospital Corporation (YHC) Board of Trustees is committed to patient safety and qualityimprovement. Board members have recently undergone an introspective review of their governance guidewhich has resulted in an improved, comprehensive set of guidelines to assist trustees in their governancework. Completion of this guide and implementation of new processes and procedures is expected in the nextfew months.

The board trustees recently received training in accessing Sharepoint which is the organization'sinternet-based software that allows access to YHC policies and procedures as well as the governance guideand reference library for the board. The reference library includes the Yukon Hospital Act, serviceAgreements, strategic plan, corporate bylaws and medical staff bylaws and rules.

The YHC mission, vision and values have guided the board and senior leadership team in the development oftheir strategic plan for 2013-2017. The current operational plan for 2014-2015 clearly outlines the activitiesto be undertaken in each of the four strategic priority areas; patient experience, organizational capability,engaged people and effective partnerships.



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to monitor and evaluate progress on the organization's efforts to mitigate or eliminate identified areas of high

risk.


The board sets performance expectations and monitors organizational performance. The board is encouraged


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3.1.3 Priority Process: Resource Management

Monitoring, administration, and integration of activities involved with the appropriate allocation and use ofresources.

The organization has met all criteria for this priority process.


Resource management in the organization is well-organized and supported by well-prepared staff members inthe financial services, materials management and facility services of the organization.

The gated process used in capital expenditures clearly delineates the capital approval process. The process issupported by business case templates and checklists that remind those submitting requests about thestrategic priorities of the organization and quality, safety and risk impacts of the purchase. The gated process

also includes an evaluation of the expenditure to determine whether or not it met expectations and achievedthe intended results.

The creation of a strategic and financial planning calendar for the organization will help managers, directorsand the senior leadership team in their own operational planning. Use of Sharepoint to host financialtemplates and documented process guidelines might be a consideration to expedite internal communicationand decision-making around resource management decisions.



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3.1.4 Priority Process: Human Capital

Developing the human resource capacity to deliver safe, high quality services



The organization delivers client safety training and education at leastannually to the organization's leaders, staff, service providers, andvolunteers, including education targeted to specific client safety focusareas.

10.8ROP

10.8.1 There is annual client safety training, tailored to staff needsand the organization's client safety focus areas.

MAJOR


There are numerous ways the organization supports its staff members and shows appreciation. Theoccupational health and safety (OHS) program, a day care that is accessible to staff, an on-site gym,long-service recognition awards, barbecues, and Christmas banquets are all examples of how employees aresupported. Competitive salaries and excellent benefits and a good work environment contribute to the lowturnover rate (8 % per year 2% quarterly).

There is a clinical nurse educator and staff development officer that coordinate and provide continuingeducation to staff members along with others in the organization such as the OHS officer and the infectionprevention and control nurse. Despite some of the education being mandatory, staff attendance andcompletion of mandatory education is lacking. As previously noted, this is a safety issue and requires action

by the organization to ensure its staff are trained and prepared on all mandatory topics, and that thisinformation be tracked and maintained. There were a number of comments made during the on-site surveyregarding the need for a longer and better orientation with some type of formal mentoring programparticularly for nursing related positions.

Personnel records are secured in the human resources (HR) department in a room that is locked. It wasobserved that although some files held certificates of attendance at specific courses, records of mandatoryand other forms of education were not maintained in the personnel file. Documentation for some education ison the Meditech system and some is tracked in the new electronic Learning Management System (LMS). It issuggested the organization consolidate the tracking and documentation of education, particularly mandatoryeducation in one system. It is suggested the human resources information system would help in tracking anddocumenting many aspects of personnel information, including education and immunization status.

Training for succession has proven to be a positive program for the organization and now requires review, and

positions or functional areas for succession targeted.



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3.1.5 Priority Process: Integrated Quality Management

Using a proactive, systematic, and ongoing process to manage and integrate quality and achieve organizationalgoals and objectives



The organization's leaders support leaders throughout the organization todevelop the knowledge and skills necessary to carry out ongoing qualityimprovement.

3.3

The organization's leaders provide opportunities for leaders throughout the

organization to participate in collaborative quality improvement initiatives.

3.4

The organization's leaders are involved in leading quality improvementinitiatives.

3.5

The organization's leaders implement an integrated risk managementapproach to mitigate and manage risk.

12.2

The organization's leaders provide the governing body with quarterlyreports on client safety, and include recommendations arising out ofadverse incident investigation and follow-up, and improvements made.

15.11ROP

15.11.2 The reports outline specific organizational activities andaccomplishments in support of client safety goals andobjectives.

MINOR

15.11.3 There is evidence of the governing body's involvement insupporting the activities and accomplishments, and acting onthe recommendations in the quarterly reports.

MINOR

The organization's leaders develop and implement an integrated qualityimprovement plan.

16.1


The organization's quality management council has not met for the past year while the board was discussinghow the quality management sub-committee would be structured. Safety reports to the board have becomepart of the CEO's performance report.

During the on-site survey there was evidence to suggest that the long time it has taken to work on the qualitystructure may be contributing to delays in moving the quality agenda forward. This is also affecting: ability torespond in a timely way to recommendations such as those made following the emergency response exercisein 2013; progress in the area of updating policies and procedures; taking action on plans made in response tothe Health Insurance Reciprocal of Canada (HIROC) risk assessment and following up on quality improvementin area such as hand hygiene audits and improvement initiatives. The collection of some quality and safetydata has continued. Nevertheless, work on quality is being done in an environment without a formalcoordinating or collaborating body to expedite the work.



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It is not clear how the quality and safety model is being applied at this time. There are quality content

experts in the organization that report to the executive lead on quality and it appears they are using aproject management approach to their work. This makes the dissemination of information and operationaldecision-making around quality, particularly for initiatives that impact more than one service area or programor site challenging. The loss of the collective input and work of quality management committee membersrepresents a risk to the organization and emphasizes a reactive rather than proactive approach to qualityissues.

The organization's system approach to quality and safety in areas such as finance, human resources and othernon-clinical areas is excellent. The clinical areas would benefit from the process work that has been and isbeing done in these support areas.



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3.1.6 Priority Process: Principle-based Care and Decision Making

Identifying and decision making regarding ethical dilemmas and problems.



The organization's leaders have a process for gathering and reviewinginformation about trends in ethics issues, challenges, and situations.

1.8

The organization's leaders use information about trends in ethics issues,challenges, and situations to improve the quality of services.

1.9

An objective reviewer or body reviews the organization's formal researchprojects.1.11


The organization has an excellent ethics framework, which is well-developed and based on the ethicsprinciples of beneficence and nonmaleficence, autonomy, fairness and impartiality. There is a procedure inplace highlighting how staff members can access support and how to work through the process. Thisframework however, is not clearly understood by front-line staff members. The YHC leadership recognizesthe need to revitalize the framework to increase support for staff members and to embed the framework inthe strategic planning for the organization. There is a need to incorporate a mechanism for documenting theresolution to ethic issues reviewed, as well as a need to analyze and trend emerging ethics issues. Of note isthat while front-line staff members were not familiar with the framework on ethics they all expressed how

they seek support from their manager should an ethical dilemma arise in their work place.

The organization needs to revise its research ethics policy as it was last reviewed in 2004. In particular thereis a need to ensure that the final approval for research study activity in the YHC is granted by an arms lengthcommittee or board as per National Tri-Council Policy, as opposed to final approval being granted by thesenior management team and/or the medical advisory committee.



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3.1.7 Priority Process: Communication

Communicating effectively at all levels of the organization and with external stakeholders



The organization's leaders work with the governing body to develop andimplement a communication plan to disseminate information to and receiveinformation from internal and external stakeholders.

7.4

The organization's leaders seek input from stakeholders on a regular basis toevaluate the effectiveness of their relationships with them.

7.5


The recent hiring of a Manager of Communications speaks to the organization's commitment to focus onenhancing its internal and external communications and promoting engagement of stakeholders. A priority forthe organization is the development of a communication plan.

The board has identified five stakeholder types in its governance guide in the area of stakeholderrelationships. This information will assist in the development of the communication plan and will providedirection in the area of community and government relations. More work to that which is already ongoing isrequired in the area of collaborating with partners and external stakeholders. Community partnersacknowledge there is more collaboration in the past year however, there is an appetite for morecommunication and collaboration on issues of mutual interest by partners that provide health services.

The organization's policy and procedures are in transition to a new format. There are policies and proceduresin place which were last reviewed eight years ago and others contain old references. The organization isencouraged to continue the work on policy review and updating. Sharepoint is a powerful electronic vehiclefor sharing information that is available to the board, physicians and staff. The information technology (IT)and systems department does an excellent job in implementing and supporting computer technology andsystems of electronic information that has been prioritized by the senior leadership team.



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3.1.8 Priority Process: Physical Environment

Providing appropriate and safe structures and facilities to achieve the organization's mission, vision, and goals



Given that Whitehorse General Hospital's facility was completed in 1997, it no longer meets all currentbuilding codes, requiring 'grandfathering' of select standards. The plan for staged upgrades to the physicalplant in Whitehorse is under active development.

It is understood that Watson Lake and Dawson City sites meet all codes and standards and have fullredundancy in critical operating systems.



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3.1.9 Priority Process: Emergency Preparedness

Planning for and managing emergencies, disasters, or other aspects of public safety


Standards Set: Infection Prevention and Control

The policies and procedures for identifying and managing outbreaks andpandemics are available to staff, service providers, volunteers, clients, andfamilies.

14.2

The policies and procedures include defined roles, responsibilities, andaccountabilities for staff, service providers, and volunteers who are

involved in identifying and managing outbreaks and pandemics.

14.5


The organization's leaders use the results from post-drill analysis anddebriefings to review and revise if necessary its all-hazard disaster andemergency response plans and procedures.

14.6


The Yukon Hospital Corporation (YHC) has a well-developed emergency preparedness plan with clear policiesand procedures for the various types of codes such as code red for fire, code green for evacuation, and so on.The manual is current and is comprehensive in addressing all types of emergencies that may present at any ofthe three sites that make up the YHC.

The organization has adopted the incident command system (ICS) to put into operation response to anysignificant disaster or emergency, and it links to other municipal and government agencies as part of theregional joint emergency operations centre to ensure a coordinated community response should the needarise.

During the clinical tracer, and at both sites visited namely, Whitehorse General Hospital (WGH) and WatsonLake Community Hospital (WLCH), staff members demonstrated their knowledge of the emergencypreparedness plan and were familiar with where to locate the emergency preparedness binder for furtherinformation. Drills have been conducted to familiarize staff members with the planned procedures. Work isunderway to incorporate learning modules on emergency preparedness into the new e-learning system.

Both communities that the surveyor team visited have participated in regional code orange (mass casualty)drills with their regional and territorial partners. Operation Nanook was an extensive mass casualty exerciseconducted in partnership with the Canadian Armed Forces, which took place in July 2013 in Whitehorse. Theexercise evaluation identified a number of strengths of the organization's emergency preparedness, as well asareas for improvement. It is recommended that YHC ensure there is a process in place to actionrecommendations emerging from the post-drill analysis and debriefing.

Managers at the WGH site have received basic training (ICS Level 100 & 200) in the adopted incidentcommand system model, which is aligned with the territorial response to managing major incidents. Staff



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members at the Watson Lake site have not received this training. This recommendation for basic training hasbeen brought forward in the lessons learned documentation for the past three (3) drills. The organization is

encouraged to ensure that training is undertaken, consistent with the recommendation and Accreditationstandards 14.6 and 14.7.



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3.1.10 Priority Process: Patient Flow

Assessing the smooth and timely movement of clients and families through service settings


Standards Set: Surgical Care Services

The team uses a standardized process to prioritize and schedule electiveprocedures.

6.7


The organization has implemented several strategies for managing short-term and long-term utilization andpatient flow problems. The morning huddles at 0845 hours and the discharge meetings at 1500 hours areintended to provide up-to-date information on bed demands and availability. Group problem-solving occursand efforts are made to ensure patients are safely and appropriately assigned a bed. Clinical nurse leadersthat cover the hospitals 24/7 not only provide clinical resource support, staff replacement andre-deployment, they monitor the hospitals for potential discharges. A social worker begins discharge planningon all patients shortly after admission.

A comment from a community partner was that there could be more collaboration with the First NationsHealth program and the community.

The organization is challenged to look at initiatives that are being successfully used in other jurisdictions suchas the rapid response Home Care assessor role. The assessor attends patients in the emergency departmentthat may be candidates for discharge if supports can be arranged, rather than admitting someone that does

not require acute care. Also, co-horting alternate level of care (ALC) patients and managing themappropriately such as dressing these patients for meals, activities, and socializing might also result in a returnto the home rather than a long-term-care (LTC) admission. The organization is encouraged to look at avolunteer program for the hospitals where socialization and activities could be part of their role.

There is an excellent diagnostic imaging (DI) process for 'flowing' patients with diagnostic lumpectomies viaadmitting, DI and to the operating room (OR).

It is recommended the organization re-name the highly visible binder located in the emergency departmentwhich currently has the title: Frequent Flyers. Titles such as individualized care plans or shared communitycare plans would be more appropriate.



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3.1.11 Priority Process: Medical Devices and Equipment

Obtaining and maintaining machinery and technologies used to diagnose and treat health problems


Standards Set: Diagnostic Imaging Services

The team follows the organization's policies and procedures andmanufacturer's instructions for cleaning and reprocessing diagnostic devicesand equipment.

8.9

Standards Set: Infection Prevention and Control

The organization appropriately contains and transports contaminated itemsto the reprocessing unit or area.12.9

The organization has written requirements for education, qualification, andcompetency of staff involved in the reprocessing of endoscopy devices.

13.1


The organization's leaders implement an effective preventive maintenanceprogram for medical devices, medical equipment, and medical technology.

9.7ROP

9.7.3 The organization's leaders have a process to evaluate theeffectiveness of the preventive maintenance program.

MINOR

Standards Set: Operating Rooms

The operating room team appropriately contains and transportscontaminated items to the reprocessing unit or area.

12.5

Standards Set: Reprocessing and Sterilization of Reusable Medical Devices

The organization collects information at least annually about servicevolumes and patterns of medical device use.

1.1

The organization reviews its operational plan and the information it collectsabout service volumes and equipment use to decide which reprocessing andsterilization services are offered within the organization.

1.2

The team works with others in the organization to limit the use of flash

sterilization to emergencies only, and never for complete sets orimplantable devices.

1.3

The organization conducts baseline and annual competency evaluations ofstaff members involved in reprocessing and sterilization.

2.5

The organization documents and retains records of education, training, andcompetency assessments.

2.7



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The organization limits access to the medical device reprocessingdepartment to appropriate team members, and posts clear signage limiting

access to all entry points.

3.2

The organization sets and follows policies that address the management ofthe medical device reprocessing department, the team, all aspects of thesterilization process, safety, infection control, and quality control.

4.1

When establishing or updating the team's infection prevention and controlpolicies, the team works closely with the organization's IPAC staff, team, orcommittee.

4.2

The team follows a process to establish and maintain its Standard OperatingProcedures (SOPs) for reprocessing and sterilization.

4.3

The team writes its SOPs in a clear, concise, and consistent way.4.4

The team documents and maintains policies, SOPs, standards of practice,and manufacturers' instructions in a manual.

4.6

All team members have access to the manual.4.7

The team tracks changes to policies, SOPs, standards of practice, andmanufacturers' instructions using a document control procedure.

4.10

The team leaders approve in writing new and updated SOPs.4.11

Staff members apply proper hand hygiene technique before beginning and

after completing work activities, as well as at other key points to preventinfection.

5.5

The team follows a detailed dress code while in the clean reprocessing areathat addresses clothing, hair, jewelry, artificial fingernails of any form, andcovered footwear.

5.7

If prion contamination is suspected, e.g. Creutzfeldt-Jakob disease, theteam follows accepted guidelines from the Public Health Agency of Canadato handle, quarantine, and incinerate the device, as appropriate.

8.3

The organization limits and monitors access to the storage area toappropriate team members.

10.2

The team has a documented quality management system for its

reprocessing and sterilization services that integrates principles of qualityassurance, risk management, and continual improvement.

12.1

As part of the quality management system, the team engages in an annualreview of reprocessing and sterilization activities, with formal reportsprovided to the organization's senior management.

12.2



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The quality management system documents are accessible to staff andteam members.

12.3

The team monitors compliance with policies and procedures, safe workpractices, and OHS requirements in the reprocessing unit or area.

12.5

The team leaders review the quality management system regularly.12.8

The team participates in periodic audits.12.9


The day-to-day management of devices and equipment appears to be managed well. Staff members aretrained and diligent in their efforts. The volume of devices and equipment processed is relatively small andthere may be a risk of losing sight of the critical nature of the work involved. It is suggested that theorganization set as a priority, the formalization of the processes, policies and training records and also, toclarify and reinforce expectations and permit regular feedback to ensure consistently high-quality work.



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3.2 Service Excellence Standards Results

The results in this section are grouped first by standards set and then by priority process.

Priority processes specific to service excellence standards are:

Episode of Care - Ambulatory Systemic Cancer Therapy

Healthcare services provided for a health problem from the first encounter with a health care providerthrough the completion of the last encounter related to that problem.

Clinical Leadership

Providing leadership and overall goals and direction to the team of people providing services.

Competency

Developing a skilled, knowledgeable, interdisciplinary team that can manage and deliver effective programs

and services

Episode of Care

Providing clients with coordinated services from their first encounter with a health care provider throughtheir last contact related to their health issue

Decision Support

Using information, research, data, and technology to support management and clinical decision making

Impact on Outcomes

Identifying and monitoring process and outcome measures to evaluate and improve service quality and clientoutcomes

Medication Management

Using interdisciplinary teams to manage the provision of medication to clients

Organ and Tissue Donation

Providing organ donation services for deceased donors and their families, including identifying potentialdonors, approaching families, and recovering organs

Infection Prevention and Control

Implementing measures to prevent and reduce the acquisition and transmission of infection among staff,service providers, clients, and families

Surgical Procedures

Delivering safe surgical care, including preoperative preparation, operating room procedures, postoperativerecovery, and discharge

Diagnostic Services: Imaging

Ensuring the availability of diagnostic imaging services to assist medical professionals in diagnosing andmonitoring health conditions



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Diagnostic Services: Laboratory

Ensuring the availability of laboratory services to assist medical professionals in diagnosing and monitoring

health conditions

3.2.1 Standards Set: Ambulatory Systemic Cancer Therapy Services


Priority Process: Episode of Care - Ambulatory Systemic Cancer Therapy

With the involvement of the client, family, or caregiver (as appropriate),the team generates a Best Possible Medication History (BPMH) and uses it toreconcile client medications at ambulatory care visits where the client is atrisk of potential adverse drug events*. Organizational policy determines

which type of ambulatory care visits require medication reconciliation, andthe how often medication reconciliation is repeated.

*Ambulatory care clients are at risk of potential adverse drug events whentheir care is highly dependent on medication management OR themedications typically used are known to be associated with potentialadverse drug events (based on available literature and internal data).

9.15 ROP

9.15.2 For ambulatory care visits where medication reconciliation isrequired, the organization identifies and documents howfrequently medication reconciliation should occur.

MAJOR

9.15.3 During or prior to the initial ambulatory care visit, the teamgenerates and documents the Best Possible Medication History(BPMH), with the involvement of the client, family, caregiver

(as appropriate).

MAJOR

9.15.4 During or prior to subsequent ambulatory care visits, the teamcompares the Best Possible Medication History (BPMH) with thecurrent medication list and identifies and documents anymedication discrepancies. This is done as per the frequencydocumented by the organization.

MAJOR

9.15.5 The team works with the client to resolve medicationdiscrepancies OR communicates medication discrepancies tothe client's most responsible prescriber and documents actionstaken to resolve medication discrepancies.

MAJOR

9.15.6 When medication discrepancies are resolved, the teamupdates the current medication list and retains it in the clientrecord.

MAJOR

9.15.7 The team provides the client and the next care provider (e.g.,primary care provider, community pharmacist, home careservices) with a complete list of medications the client shouldbe taking following the end of service.

MAJOR

The team has a process to provide clients with detailed instructionsregarding administration and safe handling of oral systemic cancertherapies.

13.3



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The team educates the client and family regarding preventing, recognizing,and managing side effects related to systemic cancer therapy.

13.4

The team conducts independent double checks on infusion pumps prior toadministration.

15.3

The team uses at least two client identifiers before providing any service orprocedure.

15.5 ROP

15.5.1 The team uses at least two client identifiers before providingany service or procedure.

MAJOR

Priority Process: Clinical Leadership

The team uses the information it collects about clients and the communityto define the scope of its services and to set priorities when multipleservice needs are identified.

1.2

The team's scope of services is aligned with the organization's strategicdirection.

1.3

The team regularly reviews its services and makes changes based onchanging priorities as needed.

1.6

The team has sufficient staff to accommodate clients and meet workloaddemands.

2.6

Team members have input on work and job design, including the definitionof roles, responsibilities, and case assignments, where appropriate.

4.4

Team leaders regularly evaluate the effectiveness of staffing and use theinformation to make improvements.

4.5

The team has a process for identifying and reducing risks to team memberswhile delivering ambulatory systemic cancer therapy services.

4.8

Priority Process: Competency

Team members have position profiles that define their roles,responsibilities, and scope of practice.

3.2

The organization trains and regularly reviews with the team andappropriate staff, the safe handling of systemic cancer therapy medicationsand/or contaminated materials.

5.6

Team leaders regularly evaluate and document each team member'sperformance and competency in an objective, interactive, and constructive

way.

5.11

Priority Process: Decision Support


Priority Process: Impact on Outcomes



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The team implements and evaluates a falls prevention strategy to minimizeclient injury from falls.

21.2 ROP

21.2.1 The team implements a falls prevention strategy. MAJOR

21.2.2 The strategy identifies the populations at risk for falls. MAJOR

21.2.3 The strategy addresses the specific needs of the populations atrisk for falls.

MAJOR

21.2.4 The team establishes measures to evaluate the fallsprevention strategy on an ongoing basis.

MINOR

21.2.5 The team uses the evaluation information to makeimprovements to its falls prevention strategy.

MINOR

The team informs and educates clients and families in writing and verballyabout the client and family's role in promoting safety.

21.5 ROP

21.5.1 The team develops written and verbal information for clientsand families about their role in promoting safety.

MAJOR

21.5.2 The team provides written and verbal information to clientsand families about their role in promoting safety.

MAJOR

The team follows the organization's defined quality improvement program.23.1

Priority Process: Medication Management

The organization has established guidelines for safe handling of systemiccancer therapy medications.

10.1

The team follows established guidelines for safe handling of systemiccancer therapy medications.

10.2

The team follows organizational guidelines for spills of systemic cancertherapy medications.

10.4

The team follows an organizational standard format in ordering, labeling,and administering systemic cancer therapy medications.

11.6


Priority Process: Episode of Care - Ambulatory Systemic Cancer Therapy

The organization is commended on creation of the navigator role for guiding patient access to services in thecommunity. The team's focus is collaborative and has a strong patient-centred approach to assuring thatopen, transparent and safe patient care services are provided with respect and compassion.

Priority Process: Clinical Leadership

The organization strives to recognize the unique needs of patients requiring cancer therapy, withconsideration of respect and culture diversity. The organization is encouraged to focus dedicated leadershipto developing the new team in the provision of cancer therapy services, and to also developing policies andprocedures to assure the safe use of chemotherapies for both patients and staff.



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Priority Process: Competency

The cancer chemotherapy team is committed to providing quality cancer care in a manner that is sensitive tothe unique needs of patients with systemic chemotherapies. The team works collaboratively and with ashared commitment for providing quality services.

Priority Process: Decision Support

The ambulatory services team works collaboratively to provide accurate and timely patient assessment andtreatment aligned with recognized systemic chemotherapy requirements.

Priority Process: Impact on Outcomes

The organization has a team committed to patient safety, and is encouraged to equip and train teammembers with the knowledge and tools they need to effectively perform their role.

Priority Process: Medication Management

The organization is in the process of developing safe guidelines for the handling of cancer therapies. Giventhe recent chemotherapy spill, the organization is encouraged to give high priority to completing theassociated guidelines in the safe handling of cancer therapy medications. The team works collaborativelywith a shared commitment to continuous quality improvement for assuring safe medication practices withhigh risk chemotherapies.



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3.2.2 Standards Set: Biomedical Laboratory Services


Priority Process: Diagnostic Services: Laboratory

The organization defines clear lines of accountability for laboratory servicesdelivered across the organization.

5.1

The team defines each member's responsibilities and required qualificationsin position profiles.

5.2

The team is made up of a sufficient number of qualified team members whoare able to carry out the required volume of laboratory services, day-to-dayoperations, and any other responsibilities.

5.4

The laboratory is accessible and safe for clients with limited mobility,visual, or hearing abilities.

7.3

The team ensures critical equipment such as refrigerators is protected withan uninterruptible power supply.

9.4

The team has a process to develop clear and concise SOPs that are in linewith applicable regulations and standards of practice for laboratoryservices.

11.1

The team has access to SOPs that are applicable to the activities it carriesout.

11.2

The team updates its SOPs every two years or more often if required.11.3

The team has a process to review and approve revisions to the SOPs.11.4

The team provides information or training to team members beforeimplementing a new or revised SOP, if required.

11.5

The team regularly evaluates compliance with its SOPs and makes changesas needed.

11.6

The team uses at least two client identifiers before providing any service orprocedure.

19.2 ROP

19.2.1 The team uses at least two client identifiers before providingany service or procedure.

MAJOR

The team has a policy and procedure manual for the LIS and its applicationsthat is available to team members at all times, and that is regularlyupdated to make sure it is complete and accurate.

24.1

The team has a safety offi

Rapport d'accrétidation de la Régie des hôpitaux du Yukon 2014 préparé par Agrément Canada (en...

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