St. Mary's General Hospital, Kitchener · Accreditation Report St. Mary's General Hospital, Kitchener On-site survey dates: June 21, 2015 - June 25, 2015 Accredited by ISQua Kitchener,

Accreditation Report

St. Mary's General Hospital, Kitchener

On-site survey dates: June 21, 2015 - June 25, 2015

Accredited by ISQua

Kitchener, ON

Report issued: July 9, 2015

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 todisseminate 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

St. Mary's General Hospital, Kitchener (referred to in this report as “the organization”) is participating inAccreditation Canada's Qmentum accreditation program. As part of this ongoing process of quality improvement,an on-site survey was conducted in June 2015. Information from the on-site survey as well as other data obtainedfrom the organization 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.

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© Accreditation Canada, 2015

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

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A Message from Accreditation Canada's President and CEO

Table of Contents

1.0 Executive Summary 1

1.1 Accreditation Decision 1

1.2 About the On-site Survey 2

1.3 Overview by Quality Dimensions 4

1.4 Overview by Standards 5

1.5 Overview by Required Organizational Practices 7

1.6 Summary of Surveyor Team Observations 13

2.0 Detailed Required Organizational Practices Results 15

3.0 Detailed On-site Survey Results 16

3.1 Priority Process Results for System-wide Standards 17

3.1.1 Priority Process: Governance 17

3.1.2 Priority Process: Planning and Service Design 19

3.1.3 Priority Process: Resource Management 21

3.1.4 Priority Process: Human Capital 22

3.1.5 Priority Process: Integrated Quality Management 24

3.1.6 Priority Process: Principle-based Care and Decision Making 26

3.1.7 Priority Process: Communication 27

3.1.8 Priority Process: Physical Environment 28

3.1.9 Priority Process: Emergency Preparedness 29

3.1.10 Priority Process: Patient Flow 31

3.1.11 Priority Process: Medical Devices and Equipment 32

3.2 Service Excellence Standards Results 34

3.2 Service Excellence Standards Results 35

3.2.1 Standards Set: Ambulatory Care Services 35

3.2.2 Standards Set: Biomedical Laboratory Services 38

3.2.3 Standards Set: Critical Care 39

3.2.4 Standards Set: Diagnostic Imaging Services 41

3.2.5 Standards Set: Emergency Department 43

3.2.6 Standards Set: Infection Prevention and Control Standards 46

3.2.7 Standards Set: Medication Management Standards 48

3.2.8 Standards Set: Medicine Services 49

3.2.9 Standards Set: Organ and Tissue Donation Standards for Deceased Donors 52

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iTable of ContentsAccreditation Report

3.2.10 Standards Set: Point-of-Care Testing 54

3.2.11 Standards Set: Transfusion Services 55

3.2.12 Priority Process: Surgical Procedures 56

4.0 Instrument Results 57

4.1 Governance Functioning Tool 57

4.2 Canadian Patient Safety Culture Survey Tool 61

4.3 Worklife Pulse 63

4.4 Client Experience Tool 64

5.0 Organization's Commentary 65

Appendix A Qmentum 67

Appendix B Priority Processes 68

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iiTable of ContentsAccreditation Report

St. Mary's General Hospital, Kitchener (referred to in this report as “the organization”) is participating inAccreditation Canada's Qmentum accreditation program. Accreditation Canada is an independent, not-for-profitorganization that sets standards for quality and safety in health care and accredits health organizations in Canadaand around the 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

St. Mary's General Hospital, Kitchener's accreditation decision is:

Accredited with Commendation (Report)

The organization has surpassed the fundamental requirements of the accreditation program.

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Executive SummarySection 1

Executive Summary 1Accreditation Report

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1.2 About the On-site Survey

• On-site survey dates: June 21, 2015 to June 25, 2015

• Location

The following location was assessed during the on-site survey.

1 St. Mary's 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

Infection Prevention and Control Standards4

Service Excellence Standards

Reprocessing and Sterilization of Reusable Medical Devices5

Organ and Tissue Donation Standards for Deceased Donors6

Critical Care7

Point-of-Care Testing8

Ambulatory Care Services9

Diagnostic Imaging Services10

Medicine Services11

Transfusion Services12

Biomedical Laboratory Services13

Perioperative Services and Invasive Procedures Standards14

Emergency Department15


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• Instruments

The organization administered:

Governance Functioning Tool1

Canadian Patient Safety Culture Survey Tool2

Worklife Pulse3

Client Experience Tool4


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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 (Work with my community toanticipate and meet our needs) 55 0 0 55

Accessibility (Give me timely and equitableservices) 64 0 1 65

Safety (Keep me safe)531 4 24 559

Worklife (Take care of those who take care of me)113 2 1 116

Client-centred Services (Partner with me and myfamily in our care) 143 0 2 145

Continuity of Services (Coordinate my care acrossthe continuum) 42 0 2 44

Appropriateness (Do the right thing to achieve thebest results) 852 5 8 865

Efficiency (Make the best use of resources)65 1 2 68

Total 1865 12 40 1917


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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 42(100.0%)

0(0.0%)

0 32(100.0%)

0(0.0%)

0 74(100.0%)

0(0.0%)

0

Leadership 46(100.0%)

0(0.0%)

0 83(97.6%)

2(2.4%)

0 129(98.5%)

2(1.5%)

0

Infection Preventionand Control Standards

40(100.0%)

0(0.0%)

1 29(100.0%)

0(0.0%)

2 69(100.0%)

0(0.0%)

3

MedicationManagementStandards

71(98.6%)

1(1.4%)

6 63(100.0%)

0(0.0%)

1 134(99.3%)

1(0.7%)

7

Ambulatory CareServices

36(100.0%)

0(0.0%)

6 72(100.0%)

0(0.0%)

5 108(100.0%)

0(0.0%)

11

Biomedical LaboratoryServices **

71(100.0%)

0(0.0%)

0 102(100.0%)

0(0.0%)

1 173(100.0%)

0(0.0%)

1

Critical Care 33(100.0%)

0(0.0%)

1 93(97.9%)

2(2.1%)

0 126(98.4%)

2(1.6%)

1

Diagnostic ImagingServices

67(100.0%)

0(0.0%)

0 66(97.1%)

2(2.9%)

0 133(98.5%)

2(1.5%)

0

EmergencyDepartment

47(100.0%)

0(0.0%)

0 80(100.0%)

0(0.0%)

0 127(100.0%)

0(0.0%)

0


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Standards SetMet Unmet N/A

High Priority Criteria *

# (%) # (%) #

Met Unmet N/A

Other Criteria

# (%) # (%) #

Met Unmet N/A

Total Criteria(High Priority + Other)

# (%) # (%) #

Medicine Services 31(100.0%)

0(0.0%)

0 68(97.1%)

2(2.9%)

1 99(98.0%)

2(2.0%)

1

Organ and TissueDonation Standards forDeceased Donors

37(100.0%)

0(0.0%)

2 79(100.0%)

0(0.0%)

1 116(100.0%)

0(0.0%)

3

Perioperative Servicesand InvasiveProcedures Standards

98(100.0%)

0(0.0%)

2 88(100.0%)

0(0.0%)

0 186(100.0%)

0(0.0%)

2

Point-of-Care Testing**

38(100.0%)

0(0.0%)

0 48(100.0%)

0(0.0%)

0 86(100.0%)

0(0.0%)

0

Reprocessing andSterilization ofReusable MedicalDevices

51(100.0%)

0(0.0%)

2 60(98.4%)

1(1.6%)

2 111(99.1%)

1(0.9%)

4

Transfusion Services ** 70(100.0%)

0(0.0%)

5 66(100.0%)

0(0.0%)

1 136(100.0%)

0(0.0%)

6

778(99.9%)

1(0.1%)

25 1029(99.1%)

9(0.9%)

14 1807(99.4%)

10(0.6%)

39Total

* Does not includes ROP (Required Organizational Practices)** Some criteria within this standards set were pre-rated based on the organization’s accreditation through the Ontario LaboratoryAccreditation Quality Management Program-Laboratory Services (QMP-LS).


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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

Accountability for Quality(Governance)

Met 4 of 4 2 of 2

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)

Met 1 of 1 2 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 Care Services)

Met 2 of 2 0 of 0

Client And Family Role In Safety(Critical Care)

Met 2 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)

Met 2 of 2 0 of 0

Client And Family Role In Safety(Perioperative Services and InvasiveProcedures Standards)

Met 2 of 2 0 of 0

Dangerous Abbreviations(Medication Management Standards)

Met 4 of 4 3 of 3


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Major Met Minor Met


Information Transfer(Ambulatory Care Services)

Met 2 of 2 0 of 0

Information Transfer(Critical Care)

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(Perioperative Services and InvasiveProcedures Standards)

Met 2 of 2 0 of 0

Medication reconciliation as a strategicpriority(Leadership)

Met 4 of 4 2 of 2

Medication reconciliation at caretransitions(Ambulatory Care Services)

Met 7 of 7 0 of 0

Medication reconciliation at caretransitions(Critical Care)

Met 5 of 5 0 of 0

Medication reconciliation at caretransitions(Emergency Department)

Met 5 of 5 0 of 0

Medication reconciliation at caretransitions(Medicine Services)

Met 5 of 5 0 of 0

Medication reconciliation at caretransitions(Perioperative Services and InvasiveProcedures Standards)

Met 5 of 5 0 of 0


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Major Met Minor Met


Safe Surgery Checklist(Perioperative Services and InvasiveProcedures Standards)

Met 3 of 3 2 of 2

Two Client Identifiers(Ambulatory Care Services)

Met 1 of 1 0 of 0

Two Client Identifiers(Biomedical Laboratory Services)

Met 1 of 1 0 of 0

Two Client Identifiers(Critical Care)

Met 1 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(Perioperative Services and InvasiveProcedures Standards)

Met 1 of 1 0 of 0

Two Client Identifiers(Point-of-Care Testing)

Met 1 of 1 0 of 0

Two Client Identifiers(Transfusion Services)

Met 1 of 1 0 of 0

Patient Safety Goal Area: Medication Use

Antimicrobial Stewardship(Medication Management Standards)

Met 4 of 4 1 of 1

Concentrated Electrolytes(Medication Management Standards)

Met 3 of 3 0 of 0

Heparin Safety(Medication Management Standards)

Met 4 of 4 0 of 0


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Major Met Minor Met

Patient Safety Goal Area: Medication Use

High-Alert Medications(Medication Management Standards)

Met 5 of 5 3 of 3

Infusion Pumps Training(Critical Care)

Met 1 of 1 0 of 0

Infusion Pumps Training(Emergency Department)

Met 1 of 1 0 of 0

Infusion Pumps Training(Medicine Services)

Met 1 of 1 0 of 0

Infusion Pumps Training(Perioperative Services and InvasiveProcedures Standards)

Met 1 of 1 0 of 0

Narcotics Safety(Medication Management Standards)

Met 3 of 3 0 of 0

Patient Safety Goal Area: Worklife/Workforce

Client Flow(Leadership)

Met 7 of 7 1 of 1

Client Safety Plan(Leadership)

Met 2 of 2 2 of 2

Client Safety: Education And Training(Leadership)

Met 1 of 1 0 of 0

Preventive Maintenance Program(Leadership)

Met 3 of 3 1 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 ControlStandards)

Met 1 of 1 2 of 2


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Major Met Minor Met

Patient Safety Goal Area: Infection Control

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

Met 1 of 1 0 of 0

Infection Rates(Infection Prevention and ControlStandards)

Met 1 of 1 2 of 2

Patient Safety Goal Area: Falls Prevention

Falls Prevention Strategy(Ambulatory Care Services)

Unmet 2 of 3 1 of 2

Falls Prevention Strategy(Diagnostic Imaging Services)

Unmet 3 of 3 0 of 2

Falls Prevention Strategy(Emergency Department)

Met 3 of 3 2 of 2

Falls Prevention Strategy(Medicine Services)

Met 3 of 3 2 of 2

Falls Prevention Strategy(Perioperative Services and InvasiveProcedures Standards)

Met 3 of 3 2 of 2

Patient Safety Goal Area: Risk Assessment

Pressure Ulcer Prevention(Critical Care)

Met 3 of 3 2 of 2

Pressure Ulcer Prevention(Medicine Services)

Met 3 of 3 2 of 2

Pressure Ulcer Prevention(Perioperative Services and InvasiveProcedures Standards)

Met 3 of 3 2 of 2

Venous Thromboembolism Prophylaxis(Critical Care)

Met 3 of 3 2 of 2

Venous Thromboembolism Prophylaxis(Medicine Services)

Met 3 of 3 2 of 2


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Major Met Minor Met

Patient Safety Goal Area: Risk Assessment

Venous Thromboembolism Prophylaxis(Perioperative Services and InvasiveProcedures Standards)

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, St. Mary's General Hospital, Kitchener is commended on preparing for and participating in theQmentum survey program. St. Mary’s General Hospital (SMGH) is the second-largest acute care hospital in the St.Joseph’s Health System, and is a Regional Cardiac Care Centre serving the residents of Waterloo, WellingtonCounty, and its reach extends to supporting Dufferin, Grey-Bruce regions and beyond. The SMGH is rooted in thevalues demonstrated by the founders, Sisters of St Joseph's in 1924, to serve those in need with compassion,dignity and respect.

Approximately 2,000 staff members, physicians and volunteers at SMGH provide excellent, compassionate careto hundreds of thousands of patients and families every year in five core areas of clinical focus: Cardiac Care(Regional Cardiac Centre); Respiratory Care (Level 1 Thoracic Surgery Centre); Outpatient (Day) Surgery;General Medicine and 24/7 Emergency Care.

The complex needs of the community continue to evolve. The SMGH population served is growing older, and newadvances in technology for improvements to care, minimize risk and improve communication are emerging,while costs continue to increase in a fiscally challenged environment.

The current physical plant has some departments that are situated in part of the original 1924 building. A masterplan process has been started and is in progress. The staff members at SMGH are commended for doing the bestthey can within the current physical space and work under significant challenges with accessibility, infectioncontrol and meeting Canadian Standards Association (CSA) standards.

The emerging risks being considered this year are under three categories: clinical risks; human capital; andphysical environment. There are clinical risks related to: workload, staffing and productivity; drugadministration management; dietary administration/food services; medical equipment, products, instruments,and health records management. The human capital risks relate to harassment and discrimination; andperformance management - Halogen performance software. Risks associated with the physical environmentrelated to physical security and has been addressed by a new security contract that has recently beenimplemented.

The board of directors embraces the philosophy of continuous quality improvement and Lean methodology. Allboard members have been to Thedacare in Wisconsin to identify with the opportunities that can evolve in ahealthcare setting. This site visit is part of their Lean training in which they participate. This is a skills-basedboard whose members are extremely committed and loyal to the community. Quality is an important focus ofthe board, evidenced by the commitment to work towards and improve upon quality in each fiscal year. Thisboard truly role-models the culture of quality and patient safety.

The SMGH has excellent, open relationships with its community and community partners. A number of successfulprojects and initiatives continue to evolve and in which SMGH participates. These include the expression ofinterest for patients with mental health and addictions and by proposing an integrated care bundle approachsimilar to that used in congested obstructive pulmonary disease (COPD) and congestive heart failure (CHF)populations. Additional projects include: seniors' geriatric services; development of the Waterloo Medicalcampus; pacemaker remote program; an Electrophysiology (EP) program, off-loading and ED pressure initiatives,among others. Communication was described by partners as being open, transparent and proactive. The boardand leadership at SMGH have a reputation for 'reaching out' to participate, lead and support.

There is opportunity for SMGH to consider strategic partners beyond the traditional hospital/academicrelationships with community, social and municipal services to serve the community and population better froma continuum perspective. The SMGH has lots to offer from developing leadership capacity, and offeringfacilitation for the community at the local level. In addition, there is a need to address an informationmanagement system (IMS) strategy for SMGH and for the Local Health Integrated Network (LHIN) at large, goingforward. Feedback to evolve expert leadership of an advanced cardiac program beyond this scope to include allcardiac care delivery in the LHIN was also a community feedback recommendation.

There are many longstanding committed employees, volunteers and physicians that comprise the team at SMGH.All staff members interviewed during the survey were complimentary of their team work and indicate that theyare all there to make a difference. The Talent Map survey from 2013 yielded six key themes, and are viewed asopportunities to work towards being a workplace of excellence. This included addressing workload and span ofcontrol of managers. It is noted new supervisor roles are being implemented. Line staff workload, successionplanning, talent development and safety in the workplace are all being addressed. Of note is the new securityservice implemented in 2015.

It is recommended that steps be taken to have a more frequent pulse of the organization. In addition,developing the human resources (HR) strategic plan that aligns with the 'True North' will be the road map for HRplanning.

The SMGH is moving forward with a new patient/family advisory committee. There has been tremendousfeedback and interest in moving in this direction from the community with more than 20 applicants expressinginterest. In addition, in the organization's commitment to continue to put patients first, visiting hours at SMGHhave now extended all day until 2030 hours. Overall, patients and families were overwhelmingly complimentaryof the care and support they received from the teams and individual staff members encountered at SMGH. Infact, many were 'teary' whilst conveying their compliments.

Opportunities exist to improve the environment for patients by reducing noise and interruptions. An innovativestrategy to minimize medication errors was to place silent zones around the Pyxis dispensing machines. Inaddition, a move to eliminating overhead paging and just limit to codes only should be considered.

It was a pleasure for the surveyor team to spend the past few days in a high-performing organization; anorganization with a tremendous focus on quality care and improvements to processes to maximize theexperience for all.


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There is opportunity for SMGH to consider strategic partners beyond the traditional hospital/academicrelationships with community, social and municipal services to serve the community and population better froma continuum perspective. The SMGH has lots to offer from developing leadership capacity, and offeringfacilitation for the community at the local level. In addition, there is a need to address an informationmanagement system (IMS) strategy for SMGH and for the Local Health Integrated Network (LHIN) at large, goingforward. Feedback to evolve expert leadership of an advanced cardiac program beyond this scope to include allcardiac care delivery in the LHIN was also a community feedback recommendation.

There are many longstanding committed employees, volunteers and physicians that comprise the team at SMGH.All staff members interviewed during the survey were complimentary of their team work and indicate that theyare all there to make a difference. The Talent Map survey from 2013 yielded six key themes, and are viewed asopportunities to work towards being a workplace of excellence. This included addressing workload and span ofcontrol of managers. It is noted new supervisor roles are being implemented. Line staff workload, successionplanning, talent development and safety in the workplace are all being addressed. Of note is the new securityservice implemented in 2015.

It is recommended that steps be taken to have a more frequent pulse of the organization. In addition,developing the human resources (HR) strategic plan that aligns with the 'True North' will be the road map for HRplanning.

The SMGH is moving forward with a new patient/family advisory committee. There has been tremendousfeedback and interest in moving in this direction from the community with more than 20 applicants expressinginterest. In addition, in the organization's commitment to continue to put patients first, visiting hours at SMGHhave now extended all day until 2030 hours. Overall, patients and families were overwhelmingly complimentaryof the care and support they received from the teams and individual staff members encountered at SMGH. Infact, many were 'teary' whilst conveying their compliments.

Opportunities exist to improve the environment for patients by reducing noise and interruptions. An innovativestrategy to minimize medication errors was to place silent zones around the Pyxis dispensing machines. Inaddition, a move to eliminating overhead paging and just limit to codes only should be considered.

It was a pleasure for the surveyor team to spend the past few days in a high-performing organization; anorganization with a tremendous focus on quality care and improvements to processes to maximize theexperience for all.


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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: Falls Prevention

· Diagnostic Imaging Services 15.6· Ambulatory Care Services 17.2

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

Detailed Required Organizational Practices Results 15Accreditation Report

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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 arepresented 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 16Accreditation 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: Governance

Meeting the demands for excellence in governance practice.

The organization has met all criteria for this priority process.

Surveyor comments on the priority process(es)

The board of directors of St Mary's General Hospital (SMGH) is extremely committed and compassionate aboutits role as advocates for the health care needs of the community. In 2014 the new strategic plan entitled:"Continuing the Legacy of Compassionate Care 2014-2017" was launched. The engagement strategy for thisplan occurred in two phases. Phase 1 occurred in partnership with Grand River and Cambridge hospitals andwas facilitated by external consultants. Community environmental scans and data were reviewed withcommon issues/opportunities across three organizations and were addressed in their common vision of healthcare across the Waterloo/Wellington region and another focus was on joint physician engagement.

Phase 2 was SMGH-specific and also involved these external consultants. Public engagement occurred via thisprocess as well with the board chair and president participating in a feedback-seeking exercise in a local mallto solicit input to plans and priorities. In addition, and beginning this year, the board undertook an additionalfour-hour session to collaborate with the senior team and medical leaders around the quality improvementplan (QIP) goals for this year.

The SMGH board members are leaders in performance excellence, with notable success in qualityimprovement monitoring and monitoring of operational performance indicators for finance and utilization.More recent improvements in HR utilization reporting were highlighted for the board and evidenced in a newreporting format, and this took place at the recent June meeting. Encouragement is offered the board torequest action plans also be presented and which address HR performance metrics, along with the analysisgoing forward.

Quality discussions, updates and education are important components of the board meetings, and the qualitycommittee report is always a standing item on the board agenda. It is not part of the consent agenda.

Recently, a new board member with experience in Lean management system methodology was recruited. Thisboard member participates on the quality committee of the board, bringing knowledge of Lean and keyquality and safety principles. A solid evidence-based board skills matrix is used to ensure that the SMGHboard has varying skill sets to enhance the role as a team representing the community.

The boardroom includes the board huddle board at which board members review monthly key performanceindicators (KPIs) that align to the strategic plan. This then cascades to the organization and is a focus at allteam levels for performance monitoring. This huddle process also addresses key HR indicators to monitorworkplace wellness.

Of note is the new ERM scorecard and rolls-up to the board on a quarterly basis. This is a way for the board toidentify progress towards key action items that address organizational risk as it relates to quality and patientsafety, finance, people, facility and reputation risk.

The board has made improvements to its self-evaluation process and conducts this on an annual basis. Inaddition, every board and committee meeting provides an evaluation tool for identifying strengths andopportunities for improvement of the meetings. The board members have attended Lean trainingopportunities, travelling to Thedacare Wisconsin to better identify with a high performing Lean organizationand to understand the possibilities for SMGH. Board members are also keen and are welcomed to participatein team huddles.

There is opportunity to improve board transparency via the SMGH internet site by publishing minutes, whichupon discussion, is due to start in September 2015. Given that the documentation of minutes in theorganization is detailed and excessive, encouragement is offered to consider moving to 'exception minutes'.

Board bylaws are updated in unison with the SJHS bylaws. Upon discussion identification of bylaws that areunique to SMGH is open for revision however, this has not occurred for four years. The board chair providesan annual update to the SJHS board and attends at a minimum, two meetings per year. In addition, the boardchairs of the Waterloo Wellington Local Health Integrated Network (WW LHIN) hospitals also meet quarterlyto align organizational strengths, highlight challenges and identify strategic partnership opportunities thatwill benefit all.

Orientation of new board members includes an SMGH component as well as a Lean component and OntarioHospital Association (OHA) seminars. There is an annual schedule of quality and program education sessionsand these occur at each meeting, along with a prayer or reflection and an article review. Patient stories arepresented at each quality committee meeting. Consideration for formalizing 'good news' and 'not so goodnews' stories become the norm at all board meetings is suggested. The board is recommended to exploreformal approaches to board education via the OHA or the Centre of Excellence.

The formal relationship with the St. Joseph's Health System (SJHS) is a noted strength and utilized in a waythat adds to the ability to collaborate and be good partners to provide good patient care.


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Of note is the new ERM scorecard and rolls-up to the board on a quarterly basis. This is a way for the board toidentify progress towards key action items that address organizational risk as it relates to quality and patientsafety, finance, people, facility and reputation risk.

The board has made improvements to its self-evaluation process and conducts this on an annual basis. Inaddition, every board and committee meeting provides an evaluation tool for identifying strengths andopportunities for improvement of the meetings. The board members have attended Lean trainingopportunities, travelling to Thedacare Wisconsin to better identify with a high performing Lean organizationand to understand the possibilities for SMGH. Board members are also keen and are welcomed to participatein team huddles.

There is opportunity to improve board transparency via the SMGH internet site by publishing minutes, whichupon discussion, is due to start in September 2015. Given that the documentation of minutes in theorganization is detailed and excessive, encouragement is offered to consider moving to 'exception minutes'.

Board bylaws are updated in unison with the SJHS bylaws. Upon discussion identification of bylaws that areunique to SMGH is open for revision however, this has not occurred for four years. The board chair providesan annual update to the SJHS board and attends at a minimum, two meetings per year. In addition, the boardchairs of the Waterloo Wellington Local Health Integrated Network (WW LHIN) hospitals also meet quarterlyto align organizational strengths, highlight challenges and identify strategic partnership opportunities thatwill benefit all.

Orientation of new board members includes an SMGH component as well as a Lean component and OntarioHospital Association (OHA) seminars. There is an annual schedule of quality and program education sessionsand these occur at each meeting, along with a prayer or reflection and an article review. Patient stories arepresented at each quality committee meeting. Consideration for formalizing 'good news' and 'not so goodnews' stories become the norm at all board meetings is suggested. The board is recommended to exploreformal approaches to board education via the OHA or the Centre of Excellence.

The formal relationship with the St. Joseph's Health System (SJHS) is a noted strength and utilized in a waythat adds to the ability to collaborate and be good partners to provide good patient care.


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3.1.2 Priority Process: Planning and Service Design

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



The annual operating goals are based on and aligned with the philosophy of 'True North' and the Leanmanagement system framework and are:, Patient and Family Centred Care, Quality and Patient Safety, OurPeople and Financial Stewardship. In addition, risk-based priority setting also aligns with the strategic andoperational and quality goals. Operationally, there is a patient safety and quality monitoring committeemade up of leaders and physicians that regularly review performance information to determine ensure areasof focus are foremost being addressed.

The annual operating planning cycle begins in September of each year, with wide input before submitting tothe Hospital Annual Planning Submission (HAPS) for the Waterloo Wellington (WW) LHIN in February.Consultation with annual planning also includes the Nursing Advisory Council and the Professional AdvisoryCouncil in addition to all formal leaders and staff. This includes opportunity to provide feedback to annualplanning as well as the strategic plan launched in 2014 via the Green Dot exercise. The exercise took theform of feedback boards that were placed in the main lobby of SMGH for staff and visitors to comment on.

Front-line staff members put interventions in place to address and monitor and improve the areas identifiedas priorities. In addition regular status exchanges occur. These happen daily for front-line supervisors andmanagers, and weekly with directors and vice presidents (VPs) and monthly between VPs and the chiefexecutive officer (CEO). This is an innovative way to ensure that all teams and individuals are aligned withthe True North and achieving the drivers.

Another example of embracing continuous quality improvement is that the board has requested that everystaff member implement a quality improvement this year, and it includes all board members as well, as theyare taking full accountability to do the same. The expectation is that teams monitor the number ofimprovements implemented each month with a sustainability plan associated with the improvement.

Quality presentations by Leaders to the board are also pre recorded by every department and posted on theSMGH external website as an example of communication, education and act of transparency for the public.

A key philosophy with planning and service design is that the organization is: “clinically inspired rather thanadministratively driven”.

Challenges and unexpected issues are handled with tremendous integrity and transparency. This wasevidenced in discussions regarding the recent flood in February 2015, and the recent lab-histology issue. TheSMGH is held in high regard as to how it handles unexpected situations.

The SMGH leaders identified their key community partners and stakeholders which they engage with on aregular basis. This includes other hospitals, the Cardiac Care Network (CCN), WW CCAC, Family Health teams,and others. Encouragement is offered to continue to partner along the continuum with stakeholders that canassist clients to remain in the community for their care. Such stakeholders can help the organization maintainits critical focus on acute care and enable the community service agencies (CSAs) to maintain and support

include Healthlinks partners and other community crisis and care agencies. Joint shared leadership positionson the hospital and Foundation board were highlighted as was a shared chief of staff role.

An example of excellent collaboration among the partner hospital can be seen in the recent development andsubmission of the Electrophysiology (EP) program proposal resulting in an EP lab for the WW LHIN. The WWLHIN-wide collaborative acute planning has resulted in 17 new integration councils in the WW LHIN. TheSMGH is responsible for cardiac and critical care. The goal is to improve standardization and eliminatevariation regardless of where care is delivered.

Quarterly adverse event reports are prepared for the quality committee of the board. The report on incidentsis based on level of severity, type, critical incidents, programs and services, and so on. In addition, and whichis noted as a good strategy to undertake is that quality of care reviews are also conducted on near misses.

The environmental scan and community engagement strategy is comprehensive. It includes communitydemographics and care access information for SMGH leaders to plan for the future. There is lots of goodaccess to community health information and performance in the system.

An opportunity noted during the on-site survey is to enhance the process to support change and transition forstaff. It is suggested the organization explore formal leadership development capacity positions to supportleaders to ensure success in change projects with an organizational development focus.

There is opportunity to reach out to community partners and agencies to support the mission of theorganization in partnering to support and benefit those with community needs. This perception was alsoevidenced in the community partners' discussion with those participants invited to the meeting.


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care in the community with SMGH support. Key initiatives besides the integrated care bundle project (ICCP)include Healthlinks partners and other community crisis and care agencies. Joint shared leadership positionson the hospital and Foundation board were highlighted as was a shared chief of staff role.

An example of excellent collaboration among the partner hospital can be seen in the recent development andsubmission of the Electrophysiology (EP) program proposal resulting in an EP lab for the WW LHIN. The WWLHIN-wide collaborative acute planning has resulted in 17 new integration councils in the WW LHIN. TheSMGH is responsible for cardiac and critical care. The goal is to improve standardization and eliminatevariation regardless of where care is delivered.

Quarterly adverse event reports are prepared for the quality committee of the board. The report on incidentsis based on level of severity, type, critical incidents, programs and services, and so on. In addition, and whichis noted as a good strategy to undertake is that quality of care reviews are also conducted on near misses.

The environmental scan and community engagement strategy is comprehensive. It includes communitydemographics and care access information for SMGH leaders to plan for the future. There is lots of goodaccess to community health information and performance in the system.

An opportunity noted during the on-site survey is to enhance the process to support change and transition forstaff. It is suggested the organization explore formal leadership development capacity positions to supportleaders to ensure success in change projects with an organizational development focus.

There is opportunity to reach out to community partners and agencies to support the mission of theorganization in partnering to support and benefit those with community needs. This perception was alsoevidenced in the community partners' discussion with those participants invited to the meeting.


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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.

Unmet Criteria High PriorityCriteria

Standards Set: Leadership

The organization's leaders provide leaders throughout the organization withopportunities for education on how to manage and monitor their budgets.

8.3


St. Mary's General Hospital (SMGH) is a financially sound organization, always exploring the next opportunityto be more effective and efficient. This is actually built into the vision with an aim to be the safest and mosteffective hospital in Canada, characterized by innovation, compassion and respect. It will always strive toaccomplish financial stewardship which is one of the pillars of the SMGH True North. A focus on quality-basedpractices (QBPs), integration partnerships, innovative care delivery models such as a remote pacemaker clinicare important for the organization.

There is evidence of excellent electronic tools and support available for front-line managers in business casedevelopment, variance analysis drill down, and development of action items to address inefficiencies withsupport from both the finance and decision-support analysts.

Opportunity exists to support new leaders in formal education of financial and utilization management,business case development and understanding of the HSFR.

The capital equipment funding budget (3.3M) has been approved by the resources planning and utilization(RPU) committee for 2015/16, and this includes substantial support from the Foundation. There are manyneeds in the organization for example, the equipment purchased with the start of advanced cardiac servicesat SMGH more than a decade ago is now in need of replacement. This is a challenge for the organization andinnovative ways to address this going forward are being explored.

Encouragement is offered to focus on sustainability of the 5S projects on in-patient units to de clutter andhave available only those supplies that are required for staff. During the survey it was noted that althoughthe physical plant is aged in some areas there is opportunity to improve efficiency with de-cluttering andremoval of equipment that is not being used to standardized locations.

An e-health strategy, both for internal systems along with patient-centred technology enablers and aLHIN-wide approach or beyond to achieve an integrated health information system (HIS) is required. This willimprove communication, safe practices for patients and overall efficiency for the organization.


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3.1.4 Priority Process: Human Capital

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



St. Mary's General Hospital (SMGH) has been recognized as one of 15, 2015 Top Employers in theKitchener-Waterloo-Guelph area. The organization's 2014 to 2017 strategic plan has defined" "transform theway we work by developing a culture of problem solvers across the entire organization" as one of its threestrategic priorities. In alignment with this priority the organization has committed resources to developcapacity and knowledge and to provide dedicated release-time across all levels of the organization, fromboard and foundation members to front-line leaders and staff to apply Lean thinking to the work of theorganization. Consistent with this commitment, the human resources (HR) team undertook a value streammapping exercise that followed the "journey" of staff from the decision to apply to work with SMGH toperformance appraisal, employee development, position change, and departure be it a termination,retirement, or voluntary decision to leave.

The HR team is commended for engaging staff stakeholders across the organization in providing input to thevalue stream mapping exercise, with the support of a Lean facilitator. The exercise established the currentstate, and the specifics of the actions to be taken to implement changes to reflect the desired state. Theteam is encouraged to develop evaluation metrics, along with process and outcome measures to monitor andtrack the changes over time.

The HR's 2013 to 2016 operational plan is aligned to the strategic directions of the organization for Qualityand Patient Safety, Patient and Family Centred Care, Our People and Financial Stewardship. The HR Vision is:"to inspire people to create an outstanding workplace and leave their own personal legacy". The focus onembedding Lean into the organizational culture as a means to enhancing patient experience and overallquality of care is, however, not explicitly evident in the HR strategic plan. The focus of the HR strategic planis articulated as: "aligning services for improved employee outcomes and delivering value to the clients weserve". The HR team is encouraged to develop clear definitions of the "outcomes" and "values" to be improvedand to develop metrics that permit monitoring, tracking and trending performance over the duration of theplan.

The HR statistics were provided for review for fiscal 2014-15. There is use of a stoplight presentation formatto the report; the organization is encouraged to develop targets based on peer group benchmarks and actionsfor each indicator, and show clear "owners" for each of the indicators. This appears to be the goal of phase 5of the: SMGH HR Analytics Journey (Impact); the current phase is consistent with phase 2 (Measurement).

Since the previous survey visit there has been a corporate restructuring of the HR function and substantivechange in personnel in the department. Corporate services now includes HR, finance, decision support,engineering, patient accounts and records. The new team has implemented numerous noteworthy HRpractices. There is a new performance review system aligned with the St. Joseph's Health System (SJHS)values and there are leadership development programs for supervisory, management, and director levelpersonnel. Development of the 2014-15 code of conduct is aligned with the SJHS values; a whistle blowerhotline is in place as is engagement of a new, specially trained security service to enhance staff and patientsafety. Violence and harassment prevention policy and procedures are in place and so is a health and safetypolicy. Also noteworthy are the SMGH values, principles and competency map, along with living the LEGACY

Model. Thee is paid volunteer time for staff; tuition subsidies for courses at outside institutions; employeeperks/discounts program, and a mentorship program to transfer retiree skill.

There is a joint occupational health and safety (JOHS) committee in place. A strong and highly engaged OHSteam oversees employee immunizations, ergonomics and musculoskeletal injuries, and supports root causeanalysis of employee accidents/injuries, and return to work strategies.

Leadership development and succession planning is a strategic objective for the organization. Talent mappingfor directors and managers is in progress, as is a 2015 leadership development program. A quarterly cultureindex has been developed using eight questions, based on the LEGACY framework.

The SMGH monitors the quality of its worklife culture using the Talent Map tool which has been approved byAccreditation Canada in lieu of the Worklife Pulse Tool. In the most recent iteration of the Talent Map survey(reported January 2014), the highest scores were in the areas of workplace health and safety, workenvironment, and patient and family centred care. The lowest scores were in the areas of senior leadership,work-life balance, and information and communication. Results have been shared at town hall forums and theorganization is committed to following through on action planning related to the results.

Physician credentialing provides physicians with privileges at both SMGH and the Grand River Hospital,facilitating consultations by specialists across both sites. Physician human resources is closely monitored bythe chief of staff and focuses recruitment efforts on needs and gaps. The chief of staff is commended forconducting the 360-degree review process with each of the 600 credentialed physicians, meeting to discussresults with each physician once every three years.

More than 300 actively engaged and well-orientated SMGH volunteers are being deployed in innovative ways.There is real-time patient feedback, education of patients about hand hygiene. A volunteer satisfactionsurvey is conducted and benchmarked with 59 hospitals.

It is recommended that the HR policy manual be updated and that attention be paid to 'version control'.


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(Leader, Engagement, Goals, Analytical, Customer Focused and You-Self Aware Leadership CompetencyModel. Thee is paid volunteer time for staff; tuition subsidies for courses at outside institutions; employeeperks/discounts program, and a mentorship program to transfer retiree skill.

There is a joint occupational health and safety (JOHS) committee in place. A strong and highly engaged OHSteam oversees employee immunizations, ergonomics and musculoskeletal injuries, and supports root causeanalysis of employee accidents/injuries, and return to work strategies.

Leadership development and succession planning is a strategic objective for the organization. Talent mappingfor directors and managers is in progress, as is a 2015 leadership development program. A quarterly cultureindex has been developed using eight questions, based on the LEGACY framework.

The SMGH monitors the quality of its worklife culture using the Talent Map tool which has been approved byAccreditation Canada in lieu of the Worklife Pulse Tool. In the most recent iteration of the Talent Map survey(reported January 2014), the highest scores were in the areas of workplace health and safety, workenvironment, and patient and family centred care. The lowest scores were in the areas of senior leadership,work-life balance, and information and communication. Results have been shared at town hall forums and theorganization is committed to following through on action planning related to the results.

Physician credentialing provides physicians with privileges at both SMGH and the Grand River Hospital,facilitating consultations by specialists across both sites. Physician human resources is closely monitored bythe chief of staff and focuses recruitment efforts on needs and gaps. The chief of staff is commended forconducting the 360-degree review process with each of the 600 credentialed physicians, meeting to discussresults with each physician once every three years.

More than 300 actively engaged and well-orientated SMGH volunteers are being deployed in innovative ways.There is real-time patient feedback, education of patients about hand hygiene. A volunteer satisfactionsurvey is conducted and benchmarked with 59 hospitals.

It is recommended that the HR policy manual be updated and that attention be paid to 'version control'.


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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



Quality and patient safety are one of the True North strategic directions. Going forward for 2014-2017, thethree strategic priorities include: delivering on clinical excellence; transforming work by developing a cultureof problem solvers and reaching beyond the walls to facilitate integration across the Wellington Waterloo(WW) region.

It is evident that the board and leadership of SMGH are committed to the strategic priorities and the TrueNorth. All the staff members encountered during the survey are aligned, committed and passionate to deliveron the improvements they are identifying in their workplace. There is a 'cascade' of metrics in theorganization, starting from the board room, to the senior team performance room to the front-line huddleboards In addition, there are unit leadership councils that review trends of performance and bring forwardopportunities for improvement at the huddles.

The department scorecards monitoring outcome outcomes were reviewed in cardiology. These scorecards aredeveloped for teams to understand trends, volumes and additional opportunities for improvement. Overall,the focus on ensuring the best performance to enhance the patient experience is a priority for all. Staffmembers are engaged and feel like they own the projects they are implementing.

Quality reporting across the organization is outstanding. The board and senior team are well informed oforganizational performance. Note is made of the organization-wide innovative approach to ensuring patientsand families are partnering with SMGH on their healthcare. This is evidenced in the Connect the DOTS"campaign, and which is posted organization wide. The four questions are geared towards ensuring patientshave the education they require to address their health concerns when they leave SMGH. These outline;knowing what to do if symptoms return; are there other things they should do to stay healthy; whatmedications are they taking and is there someone they can call if help is required?

The Canadian Patient Safety Culture Survey Tool and the most recent client experience survey report resultsfrom NRC Picker were made available to the surveyor team. Overall, the focus on patient safety is alsoevidenced in working towards improving access to the emergency department (ED) this year and in addition,improving the falls rates across the organization. With respect to client experience, the staff members wearidentifying badges along with their name badges to ensure they are readily identified for patients. Thevalues of the organization of respect and their belief in the sacredness of life and dignity of all peoplecontinues to be a focus. Opportunities identified by patients as themes for improvement includecommunication by providers, support for fears and anxieties, information about their tests, and response tobells.

There is opportunity to move towards simplicity in quality structure and reporting in the organization. Thereare notable silos among teams and where staff report to on role clarity, relationships, who reports on whatand what process or outcome projects were in place and led by whom. Reports did not always appear to bealigned. All systems appeared to be valuable however, there is opportunity to review tools, reports andstreamline this in the organization to keep things simple for staff, and to have the best impact on patients

operations. Alignment of outcome and process improvement projects and metrics is encouraged with a focuson a select few priorities.

In addition, encouragement is offered to continue to monitor compliance of the prospective analysis that wasimplemented as a pilot on the sixth floor last year and which is to be rolled out organization wide. Thisfailure modes effects analysis (FEMA) is entitled: "Medication Dispensing - Quiet Zone". Implementing andaddressing changes and improvements based on feedback from staff members is important. There is need tocontinue to monitor compliance and for sustaining the initiative.

An additional opportunity exists in the utilization of the reports from the upgraded RL solution and programs(one-stop) that are available. It is recommended that SMGH capitalize on the power of the information tocontinue to drive safe practices in the organization. The reports from this system are extremely importantand full functionality is encouraged. Communication back to the staff members by supporting closing-the-loopon reported incident reports, root cause analysis or quality of care reviews is important to assist leaders inrole modelling a Just Culture.


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with data and information readily available. There are separate teams for quality strategy and qualityoperations. Alignment of outcome and process improvement projects and metrics is encouraged with a focuson a select few priorities.

In addition, encouragement is offered to continue to monitor compliance of the prospective analysis that wasimplemented as a pilot on the sixth floor last year and which is to be rolled out organization wide. Thisfailure modes effects analysis (FEMA) is entitled: "Medication Dispensing - Quiet Zone". Implementing andaddressing changes and improvements based on feedback from staff members is important. There is need tocontinue to monitor compliance and for sustaining the initiative.

An additional opportunity exists in the utilization of the reports from the upgraded RL solution and programs(one-stop) that are available. It is recommended that SMGH capitalize on the power of the information tocontinue to drive safe practices in the organization. The reports from this system are extremely importantand full functionality is encouraged. Communication back to the staff members by supporting closing-the-loopon reported incident reports, root cause analysis or quality of care reviews is important to assist leaders inrole modelling a Just Culture.


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3.1.6 Priority Process: Principle-based Care and Decision Making

Identifying and decision making regarding ethical dilemmas and problems.


Standards Set: Leadership

The organization's leaders build the organization's capacity to use the ethicsframework.

1.7


The staff members are committed to living by their faith-based values, and this is especially noted in thevalue of serving the poor and marginalized. This has been and is a unique area of focus for the organization.The chief executive officer reports on mission and values to the St Joseph's Health System (SJHS) on aquarterly basis.

Of note is the patient declaration of values (PDOV) which are well-communicated and available for patientsand visitors. The PDOVs were developed in partnership with the Wellington Waterloo Local Health IntegratedNetwork (WW LHIN) and are standardized across the communities. This has been an extensive andwell-orchestrated undertaking as there is variation in organization culture and community expectations acrossthe LHIN.

There is an organizational ethics committee that addresses both clinical and non-clinical ethical situations asthese arise and keeps the organization current in external trends. The ethicist is shared with other SJHSorganizations and there is someone available urgently for the organization on a 24/7 basis. Educationalrounds/events for staff members are available on a quarterly basis. Workshops and drop-in events withclinical directors and their teams occur on a monthly scheduled basis. This is a forum in which staff membersare able to address ethical situations that they have faced with the ethicist.

Capital planning and resource allocation also follows an ethical process with patient safety and quality ofcare at the centre of the decision.

There is a Tri-Hospital Research Ethics Board which is representative of three organizations namely; SMGH,Grand River and Cambridge hospitals. This board is available with both a solid reporting and evaluationcomponent built in. Encouragement is offered to review the membership and continue to work on engagingphysicians in the value of participating in decisions with respect to peer research and impacts on theirpatients. Currently, there is currently only one physician that participates and represents the threeorganizations.

Recently, a new ethics framework has been adopted and is in process of being rolled out at SMGH. Theframework, YODA which translates to You-Observe-Deliberate-Act requires education for staff, along withopportunity to enhance staff capacity for ethics consultation and how to address dilemmas. The currentprocess as identified by staff members is to call their manager and the manager would contact the ethicist ora member of the ethics committee. Encouragement is offered to explore ways to build capacity in thefront-line clinical staff.


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3.1.7 Priority Process: Communication

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



The organization is currently at an awkward phase in the move toward digitization of the charts. The currentsituation is that the charts are half digitized and half paper. A full picture of a patient's condition cannot beobtained without first looking at both types of charts. It appears that there is an early plan for fulldigitization, but there does not seem to be much progress in this regard. The staff members see the value offull digitization, and are becoming impatient at the delay in its implementation. This could be looked on asan opportunity for significant improvement.

Communications at SMGH is an established priority. Communication is facilitated and reviewed on at least anannual basis with all professional and community stakeholders and staff. The communication wasacknowledged to be gold standard during and after the recent flood, with people affected able to access theappropriate information in a timely manner. Communication was key during the February flood forcoordination of responses.

All stakeholders are regularly consulted, and communication techniques and needs are regularly reviewed.The intranet is a good resource for all hospital employees. It is reviewed and updated regularly. All files haverestricted to use protection and confidentiality is assured.

A television whereby patients can access an information site is in the process of being finalized, and shouldbe in place by September 2015.


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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



At its October 2014 retreat the board and senior leadership team rated the Physical Environment insofar asconstruction and maintenance as its top Enterprise risk. The physical infrastructure of St. Mary's GeneralHospital (SMGH) has been calculated to have an average age per square foot of 49 years. The facility wasconstructed in seven distinct phases, with building upgrades and/or additions from 1923 to 2008. The "new"mechanicals more than 10 years old and the electrical grid is in a bunker located below ground level in anarea with a risk of flooding due to both aging local municipal water systems and weather-related flashstorms.

The SMGH is encouraged to continue to advocate for the plan developed in its Stage 1 Master Plan proposalfor redevelopment at the existing site, or a new build to address population growth in its core servicedelivery areas of focus, to address the problem of the current physical facilities lacking functionaladjacencies and efficiencies, as well as to address its aging infrastructure. The recommendation for a newbuild is aligned to regional service delivery priorities that include: enhanced ambulatory services; adherenceto infection prevention and control (IPAC) standards, improvement and increased efficiencies in the flow ofpatient care, and increased efficiencies in delivery of support services.

The SMGH's engineering department's centralized computerized maintenance management system is animpressive asset management system. The system effectively supports the maintenance of the aging physicalplant and capital equipment of the SMGH facilities. Both on-demand and preventive maintenance areperformed and efficiently tracked to completion, including labour costs on a per item basis. Manufacturers'guidelines and standard operating procedures guide practice. The engineering team has a good handle on therisks of the physical environment.

Renovation and construction projects have significant input from and emphasis on infection prevention andcontrol (IPAC) and safety. Although not a specific safety concern, the clinical spaces are sub-ideal for bothIPAC and privacy/confidentiality. Many of the rooms in the hospital are of older design, and have geo-spatiallimitations when placing patients in accordance to current provincial standards for isolation.

Notwithstanding the age of the SMGH physical plant, the buildings and mechanicals are well maintained, andthe public and patient areas are clean and orderly. The organization has done a good job of creating a warm,inviting environment for patients and families. The clutter in clinical areas that was observed at the previoussurvey and noted in the 2011 accreditation report is still evident today. The surveyor team observed clutterin some clinical areas during the tracers conducted during this on-site visit. The organization is encouraged tocontinue its Lean-focused efforts to manage inventory and equipment storage in light of space and physicallayout, especially in the older areas of the hospital.

There is attention given to waste diversion and reporting of energy consumption. The organization's wastereduction work plan for 2014-15 is posted on the SMGH public website, as is a summary of gas emissions andconsumption, and the five-year (2014-19) plan for greenhouse gas emissions and energy consumption. TheSMGH has been recognized as an Ontario Top 10 performer as a Green Hospital.


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3.1.9 Priority Process: Emergency Preparedness

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



The SMGH leadership and staff members demonstrated an impressive response to the bursting of themunicipal water main that resulted in a flooding incident at approximately 0400 hours on February 8 2015.The incident led to the activation of SMGH's Emergency Operations Centre (EOC) as the entire basement ofthe hospital became flooded with over 7.5 feet of water. Services disrupted included nutrition and foodservices, pharmacy, engineering, medical device reprocessing unit, and environmental services. All elevatorsto the basement were also out of service. The situational and dramatic irony of having four AccreditationCanada surveyors staying at a hotel in Waterloo and engaged in their planning session for SMGH's on-sitesurvey to begin the next day...was not lost on the organization or the surveyors! Kudos are extended to theSMGH leaders, staff members and their general community for their robust management of this emergency,and especially their focus on the safety and care of their patients.

The handling of this emergency is a testament to the strength of the organization's emergency planning.Planning is inclusive of a highly engaged multidisciplinary emergency planning committee, and regular reviewand testing of plans that are updated and strengthened based on experience. This includes a postincident/exercise analysis and review of templates completed for the February flood incident. The analysisyielded 38 opportunities for improvement in spite of the general consensus that the handling of theemergency was exemplary and based on emerging evidence in the science of emergency preparedness.

The emergency planning committee has a well-developed work plan for 2014 to 2016 complete with targetdates for each activity. There are good linkages between SMGH and provincial and local municipality levelsfor emergency preparedness, including a contract with a local high school as an off-site muster area. It isacknowledged that SMGH has followed an excellent process of debriefing from the flood incident and lessonslearned from this incident are being acted on, and will inform ongoing dialogue regarding emergencypreparedness, role adjustments, and other things. It is noteworthy that public communications as the floodincident unfolded were both timely and informative.

The organization conducts regular drills related to the emergency plan, mock exercises and table-topexercises and debriefs after every event. Although fire safety is also well planned and managed, theorganization is encouraged to implement fire drills that are scheduled strategically to address factors onvarying shifts to cover evenings and nights on week days and weekends.

Fire safety is a priority due to the age of the various sections of the hospital. Orientation for new hiresincludes learning about emergency preparedness. New staff members do not initiate their work duties untiltheir emergency and safety orientations have been completed. Education for patients, families and visitorswas not apparent; SMGH may wish to include fire safety and fire prevention information for the public ontheir websites, as many organizations do this.

The SMGH emergency response plan is built on the incident management system (IMS) model and is easily"scalable". Colour codes were well understood by staff members when questioned during the on-site tracers.Security services are provided under a new contract and security personnel questioned during tracers werewell-versed in the SMGH emergency codes and plans, and their response responsibilities related to the codes.

security service and security response times since the new contract came into effect in 2015.

Pandemic planning is based on international, national and provincial evidence, and provincial directivesrelated to Ebola are implemented. Overall, the emergency preparedness team is coordinated, integrated andsolution driven. A commitment to quality, safety and ongoing improvement is evident in the action plans.


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All staff members that were questioned during tracers commented on the superior level of the quality of thesecurity service and security response times since the new contract came into effect in 2015.

Pandemic planning is based on international, national and provincial evidence, and provincial directivesrelated to Ebola are implemented. Overall, the emergency preparedness team is coordinated, integrated andsolution driven. A commitment to quality, safety and ongoing improvement is evident in the action plans.


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3.1.10 Priority Process: Patient Flow

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



Patient flow is carefully monitored and proactively managed. The team has a manager in charge of patientflow. This manager holds a daily meeting with representatives from all patient care areas. Every patient inthe hospital is looked at, the status is reviewed, and a decision is made as to that bed status for the day.There is close co-operation with operating room (OR) booking and the emergency department. There areextra "surge" beds to allow for some flexibility.

The whole process works well, and when asked there were no instances of surgery being cancelled for lack ofbeds, based on staff memory. The St. Mary's General Hospital is seldom on diversion and works closely withother regional hospitals to avoid these occurrences.


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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 individual responsible for the overall coordination of reprocessing andsterilization activities within the organization oversees the team'scompliance with the organization's policies and procedures on cleaning andreprocessing.

8.12

Standards Set: Reprocessing and Sterilization of Reusable Medical Devices

The designated person reports directly to the organization's seniormanagement or the executive office.

1.5


The main SMGH medical devices and reprocessing department (MDRD) meets all best practice standards forwork flow and has good resources, with both the staffing and reprocessing/sterilization equipment to meetthe service needs of its downstream stakeholders.

Accountability and responsibility for sterilization and reprocessing activities in the organization are clearlydelineated.

At SMGH the MDRD leader is a supervisor that reports to a director. Consider reviewing the oversite of theMDRD and DI department in regards to reprocessing.

Risks associated with medical devices reprocessing/sterilization in the main department are prevented,where possible, or identified and managed. Where incidents occur these are thoroughly reviewed using a rootcause analysis (RCA) approach with the entire team. Risk occurrences are trended and posted for all staffmembers to review and are discussed during daily huddles for example, sharps/blades in packs returned fromthe OR.

Staff members working in the area are proud of their work, receive orientation and ongoing real-time trainingas needed when changes in protocols that will impact all staff are implemented, or when individualdevelopment is needed to support performance issues. Staff members are looking forward to the pendingLean wave training.

The local cystology procedure area operates a satellite reprocessing/sterilizing function. There is an absenceof one-way work flow in this area to separate clean and dirty items. The SMGH is encouraged to implementthe recommendation of the IPAC team to have a barrier erected at one end and have the "clean cart"assembled in either the cysto-suite, or in the reprocessing room and covered and transported via the hallwayto the procedure room. An interim workaround has been put in place whereby the sterile instruments aretransported on a covered tray via the corridor to the procedure room, such that no clean items are to passthrough the "dirty" door. It was also noted during the tracer that cleaned scopes are hung on a rack mounted

An on-site review of a random number of policies and procedures for the MDRD found that all were clear,thorough and well- documented, and had excellent version control.

The leadership of the MDRD is commended for developing a made-at-SMGH instrument tracking system.Undeterred by the lack of funds to purchase a proprietary computer instrument tracking system that an RFIindicated exceeded the available budget, the MDRD team developed an instrument inventory and trackingsystem using Microsoft. The computer system includes photos, which staff members during the tracerreported they use with "every" tray they set up.

Biomedical engineering services are provided to SMGH as a contracted service from the Grand River Hospital.During the tracers clinical staff members reported that the biomedical engineers are consistently timely andresponsive to their requests for assistance with their equipment problems. Requests are logged on the SMGHcentralized computerized equipment management system for tracking purposes, both for on-demand repairsand preventive maintenance and are logged. The organization has a capital equipment prioritization processand is aware of the magnitude of capital items nearing end-of-service or already obsolete such as the GE Dashpatient monitors for which the manufacturer is no longer supporting repairs or providing parts.


on the wall along the route of dirty to clean.

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An on-site review of a random number of policies and procedures for the MDRD found that all were clear,thorough and well- documented, and had excellent version control.

The leadership of the MDRD is commended for developing a made-at-SMGH instrument tracking system.Undeterred by the lack of funds to purchase a proprietary computer instrument tracking system that an RFIindicated exceeded the available budget, the MDRD team developed an instrument inventory and trackingsystem using Microsoft. The computer system includes photos, which staff members during the tracerreported they use with "every" tray they set up.

Biomedical engineering services are provided to SMGH as a contracted service from the Grand River Hospital.During the tracers clinical staff members reported that the biomedical engineers are consistently timely andresponsive to their requests for assistance with their equipment problems. Requests are logged on the SMGHcentralized computerized equipment management system for tracking purposes, both for on-demand repairsand preventive maintenance and are logged. The organization has a capital equipment prioritization processand is aware of the magnitude of capital items nearing end-of-service or already obsolete such as the GE Dashpatient monitors for which the manufacturer is no longer supporting repairs or providing parts.


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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:

Point-of-care Testing Services

Using non-laboratory tests delivered at the point of care to determine the presence of health problems

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 programsand 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 monitoringhealth conditions

Transfusion Services

Transfusion Services

3.2.1 Standards Set: Ambulatory Care Services


Priority Process: Clinical Leadership


Priority Process: Competency


Priority Process: Episode of Care


Priority Process: Decision Support


Priority Process: Impact on Outcomes

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

17.2 ROP

17.2.1 The team implements a falls prevention strategy. MAJOR

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

MINOR



For this survey, two services were included in the ambulatory care tracer: the SMGH Airway clinic and theSMGH Geriatric Medically Complex clinic. Both clinics are excellent examples of using data and informationabout community needs to develop services for target populations.

The Airway clinic offers out-patient respiratory services. The clinic is, in fact, nine different clinics thatprovide education, rehabilitation, diagnostic, and community outreach services for non-admitted patientswith congestive obstructive pulmonary disease (COPD), Asthma, adult Cystic Fibrosis, and patients at risk oflong-term ventilation. The clinic's multidisciplinary team members include respiratory therapists,

clinic's services align to the SMGH strategic priority of "reaching beyond the SMGH walls", and are focused onpreventing emergency (ED) visits and hospital admissions. Some of the clinics are offered in the communityfor example, in community health centres and offered on a fee-recovery basis to family health teams, and inremote communities via telehealth services. Family doctors or respirologists make referrals to the clinic.

The Geriatric Medically Complex clinic is a demonstration pilot project offered by SMGH. The targetpopulations for the clinic are medically complex frail elders 60 years of age and older with multipleco-morbidities that present with geriatric syndromes, such as delirium, falls, cognitive decline, failure tocope, or caregiver stress. This clinic also aligns to the SMGH strategic direction of: "reaching outside thewalls", as the goal is to support medically complex patients that have sub-optimal access to primary careproviders or who do not utilize primary care providers, instead presenting in crisis to the ED.

Both clinics have developed partnerships and collaborations with internal services provided by SMGH to assistthe teams to deliver quality services. Partnerships and collaborations include the SMGH Physio gymnasiumand SMGH clinicians such as physiotherapists, social work, clinical nurse specialists and nurse practitioners.

The culture of both teams is extraordinary. Team members expressed commitment to their roles,individually, and for the role of the team collectively, in delivering a service that is highly valued by thepatients and their families accessing these services, as well as the referring clinicians.


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physiotherapists, kinesiologists, and social workers. The team works closely with SMGH's respirologists. Theclinic's services align to the SMGH strategic priority of "reaching beyond the SMGH walls", and are focused onpreventing emergency (ED) visits and hospital admissions. Some of the clinics are offered in the communityfor example, in community health centres and offered on a fee-recovery basis to family health teams, and inremote communities via telehealth services. Family doctors or respirologists make referrals to the clinic.

The Geriatric Medically Complex clinic is a demonstration pilot project offered by SMGH. The targetpopulations for the clinic are medically complex frail elders 60 years of age and older with multipleco-morbidities that present with geriatric syndromes, such as delirium, falls, cognitive decline, failure tocope, or caregiver stress. This clinic also aligns to the SMGH strategic direction of: "reaching outside thewalls", as the goal is to support medically complex patients that have sub-optimal access to primary careproviders or who do not utilize primary care providers, instead presenting in crisis to the ED.

Both clinics have developed partnerships and collaborations with internal services provided by SMGH to assistthe teams to deliver quality services. Partnerships and collaborations include the SMGH Physio gymnasiumand SMGH clinicians such as physiotherapists, social work, clinical nurse specialists and nurse practitioners.

The culture of both teams is extraordinary. Team members expressed commitment to their roles,individually, and for the role of the team collectively, in delivering a service that is highly valued by thepatients and their families accessing these services, as well as the referring clinicians.


The clinicians working in each of the Airway and Geriatric Complex Medically Complex clinics offer a veryunique skill set to meet the needs of their respective client populations.

The clinical environment appears to be one of mutual respect amongst disciplines. Staff members that wereinterviewed during the tracers reported feeling involved in decision-making regarding their work with theirpatients and reported feeling listened to when they have suggestions for improvement.

A strong commitment to excellence in care and provided to each of the patient populations was evidentduring tracers, and further supported by feedback from the patients that were interviewed or observedduring the tracers. Staff members reported being well supported by their leadership team, as well as havingtimely information and mentorship to do their job. Leadership development and mentorship were also notedwith appreciation.

Staff members are committed to keeping competencies current and report support from the managementteam for ongoing professional development. Specialized training is encouraged and supported. Professionalcredentials and licensing are tracked by the human resources (HR) department.


The staff members at both the ambulatory care clinics visited are committed to meeting the needs of theirpatients and families and express a passion for their work and for being a part of St. Mary's General Hospital(SMGH). There is clear evidence of a desire to evaluate and continually improve the effectiveness ofinterventions for every patient and to improve the effectiveness of the clinic overall.

Community partnerships and examples of collaborative problem solving and program planning to meet theneeds of the shared clientele were provided. Clinicians work closely with patients and their families to definetheir service goals, to monitor progress and re-evaluate goals over time. In both clinics there is a streamlined

formal processes for admitting clients, and patients are screened to match the clinic's focus.

The patient and clinician relationships observed during the tracers were impressive in both cases and thepatients were active participants in decision-making regarding their care, demonstrating a clear focus bystaff on patient-centred care. Patients described staff members as caring, and expressed satisfaction withthe services they received. Two client identifiers were observed to be used to confirm the identity ofpatients.

All providers were observed to adhere to hand-hygiene protocols.


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intake process, short wait times for admission, and excellent responsiveness to those referring. There areformal processes for admitting clients, and patients are screened to match the clinic's focus.

The patient and clinician relationships observed during the tracers were impressive in both cases and thepatients were active participants in decision-making regarding their care, demonstrating a clear focus bystaff on patient-centred care. Patients described staff members as caring, and expressed satisfaction withthe services they received. Two client identifiers were observed to be used to confirm the identity ofpatients.

All providers were observed to adhere to hand-hygiene protocols.


Both the ambulatory care clinics visited during the survey are highly specialized. Sharing of evidence-basedguidelines occurs, and staff members are aware of the value this brings to their work.

The Airway clinic is encouraged to consider pursuing involvement in both basic and clinical researchactivities. The Geriatric Medically Complex clinic is encouraged to define more robust measures to strengthenthe quantitative indicators of success relative to the goals of the program.


The Airway clinic team has drafted a falls screening and referral algorithm, has chosen a test of basicfunctional mobility for frail elderly persons (Timed Up and Go Test), and has developed a community-basedfall risk education and assessment letter template to be sent to the referring or attending physician, outliningtheir patient's TUG score.

The falls prevention strategy is not yet implemented in the Airway clinic. A measure (TUG test scores) hasbeen determined for ongoing use. Measurement has not yet yielded data that can be interpreted asinformation upon which to evaluate or base improvements to ameliorate risk of falls for the Airway clinicpatients, or to make changes that are improvements to the organization-wide falls prevention strategy. TheAirway clinic leadership is involved with the work of the out-patient/ambulatory task group of theRehabilitation Care Alliance to develop data elements and indicators for benchmarking.

The Geriatric Medically Complex clinic focuses on providing: "the right care at the right time by the righthealth care professional". The team has developed a triage tool with specialized geriatric services for urgentcommunity assessments, an ED referral form and a process for urgent referrals from the ED or the communityto be seen within 72 hours.

In both clinics there is clear evidence of collaboration between clinicians at team meetings and/or teamhuddles.

Transition planning for patients seen in the Airway clinic is excellent. There is evidence of a process tofollow-up with patients after transition or end of service. For example, patients in the congestive obstructivepulmonary disease (COPD) Activation program are called by the respiratory therapist six to eight weeks afterthe end of the five-week program, and patients become "alumni" of the program.


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3.2.2 Standards Set: Biomedical Laboratory Services


Priority Process: Diagnostic Services: Laboratory



Priority Process: Diagnostic Services: Laboratory

St. Mary's General Hospital (SMGH) laboratory staff members have just completed a successful OntarioLaboratory Accreditation (OLA) review. This laboratory reflects one of the integrated programs between theGrand River and St. Mary's hospitals, with shared program physician leadership structure and tailoredlaboratory services reflecting the different health populations each of the hospitals serve. Prior to thesurveyor team visit SMGH's laboratory underwent the aforementioned OLA accreditation process and received100% compliance with OLA's standards, surpassing the 98% standing from its previous assessment.Congratulations are extended to leaders and staff for this commendable standing.

The senior leadership group presented a comprehensive report outlining targets for service delivery on turnaround times, performance indicators and action items. The report reflected achievements to date andstrategic targets going forward in this next year. In addition to this report, the recent "Client SatisfactionSurvey Report-2014" was highlighted in the presentation. This satisfaction survey was circulated to targetedhospital disciplines for their opinions on SMH laboratory performance. Satisfaction levels reflect a minorchange in the two years since the last survey of approximately the same sample size. The leadership is notdiscouraged and is putting their energies into defining aggressive targets for the areas highlighted forimprovement.

The leadership is encouraged to continue to pursue a fully integrated laboratory system with its partnerhospital and sustain its laudable rating with OLA in the upcoming years.


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3.2.3 Standards Set: Critical Care







If the team offers outreach services in the form of a rapid response ormedical emergency team, it defines the role of this team andcommunicates it to other teams in the organization.

3.2

When offering outreach services, such as a rapid response or medicalemergency team, the team provides other organizational teams with thestandardized criteria it uses to determine whether critical care services willbe provided.

6.3





Priority Process: Organ and Tissue Donation




There is appropriate interaction with the community and other members of the Local Health IntegratedNetwork (LHIN) to plan services and objectives. Measurable and specific goals and objectives are developed.


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and incomplete patient privacy.

Staff members are encouraged to seek further education opportunities. Education activities are documented.

Team members have access to a rest area. Team accomplishments are recognized.


There is timely access to service for all clients. The client is educated about rights, and disputes areinvestigated and solved quickly. A venous thrombo embolism (VTE) protocol is in place. A best possiblemedication history (BPMH) and medication reconciliation are carried out at regular intervals. Informedconsent is always obtained, and the client is always kept fully informed of their condition. Sedation ismonitored appropriately. Restraints are used appropriately. Pressure ulcer and falls assessments aredocumented. Medications are handled properly.


Client records are kept appropriately. They are current, accessible and secure. Guidelines are reviewedregularly and kept up to date, using evidence-based principles.


The team identifies its objectives and identifies the resources needed to meet them. Risks to team membersand patients are identified and dealt with, and regular safety briefings are held. Adverse events are disclosedto clients. The client and family are informed of their role in promoting safety.

Quality improvement is given high priority. Every unit displays its quality improvements (QI) and projects forQI are identified and tracked with appropriate feedback to the community and staff.


The organ donation process is largely managed by the Trillium Gift of Life Network. After a potential donor isidentified at SMGH, the TGLN is notified and a donor manager is dispatched. The donor manager then takescare of all the details of donation.



There is an interdisciplinary team with well-defined roles. Staffing levels are set according to work loads.Skill development in team members is encouraged.

The workspace provided is sufficient, but the layout is quite dated, with curtains between many of the beds

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3.2.4 Standards Set: Diagnostic Imaging Services


Priority Process: Diagnostic Services: Imaging

The physical environment has clear signage in place to direct clients to theimaging service.

4.1

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

15.6 ROP

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

MINOR

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

MINOR


Priority Process: Diagnostic Services: Imaging

The diagnostic imaging (DI) priority processes included general radiology, ultrasound, computed tomography(CT) scan, nuclear medicine and cardiac diagnostics. The physical environment is accessible and spacious inall areas. Privacy and safety for patients is well maintained. All patients interviewed during the visit in theseareas indicated they were well informed in advance, wait times were minimal and they were providedinformation about what to expect.

The nuclear medicine regional program is situated at St. Mary's General Hospital (SMGH). The supervisor isshared with Grand River Hospital which continues to maintain a program. Performance data are shared withthe Grand River Hospital on a regular basis. There is no magnetic resonance imaging (MRI) at SMGH. Patientsrequiring this diagnostic service are transferred to the Grand River Hospital.

The excellent monitoring of on-time starts for CT, thyroid and prostate biopsies has seen notableimprovements. In addition, monitoring of turn around times for CT and ultrasound (US) and wait times for CT,US and x-ray were noted in DI.

To ensure safety for patients that are waiting for procedures in nuclear medicine, those that have completedthe procedure and are considered 'hot' have a separate place in which to sit when finished, which is apartfrom those waiting.

Of note is the impressive project was recently undertaken to address the time it took for sentinel nodebiopsies by the nuclear medicine team. This project, to address length of time and number of interventionsand also minimize moves for patients across departments, resulted in an overall improvement to the patientexperience by shaving three hours off the time it took to perform the procedure.

The DI and nuclear medicine departments have way-finding that is not easily identified, signs that are raisedhigh, neutral colours to walls and are a challenge for seniors. It is recommended a review of way-finding forthese departments be carried out after the new CT is installed.

tracking the cleaning back to the patients on whom probes were used, there is no oversight from the lead ofsterilization in the organization to ensure staff training and cleaning standards are being maintained.Consideration for reviewing standards for disinfecting and oversight are encouraged in order to makeimprovements and maintain safe standards to minimize transmission issues that can occur between patients.

It is recommended that the IPAC team review the locations of the hand-hygiene stations in the out-patientdiagnostic areas. There does not appear to be as many stations readily available upon entering and exitingexam rooms as there were in the in-patient areas.

A survey of referring physicians was completed two years ago. Recent availability of local physicians tocontact to review and seek feedback in follow-up going forward is available from the office of the chief ofstaff.

While risk for falls is available on the referral form as a tick box, the data regarding falls in DI is printedwithin an overall annual report from the RL risk report. At the time of survey there is no evidence of anongoing process to measure more regularly such as monthly or quarterly the impact of the falls preventionstrategy that has been implemented in DI.


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tracking the cleaning back to the patients on whom probes were used, there is no oversight from the lead ofsterilization in the organization to ensure staff training and cleaning standards are being maintained.Consideration for reviewing standards for disinfecting and oversight are encouraged in order to makeimprovements and maintain safe standards to minimize transmission issues that can occur between patients.

It is recommended that the IPAC team review the locations of the hand-hygiene stations in the out-patientdiagnostic areas. There does not appear to be as many stations readily available upon entering and exitingexam rooms as there were in the in-patient areas.

A survey of referring physicians was completed two years ago. Recent availability of local physicians tocontact to review and seek feedback in follow-up going forward is available from the office of the chief ofstaff.

While risk for falls is available on the referral form as a tick box, the data regarding falls in DI is printedwithin an overall annual report from the RL risk report. At the time of survey there is no evidence of anongoing process to measure more regularly such as monthly or quarterly the impact of the falls preventionstrategy that has been implemented in DI.


Disinfection and cleaning of probes both in DI and cardiac diagnostics are noted. While the staff members are

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3.2.5 Standards Set: Emergency Department
















Input is received from stakeholders and used to meet the needs of the population served. The emergencydepartment (ED) team has access to the resources it needs. It is felt that the physical space is adequate tocover the needs of St. Mary's General Hospital, but that a larger and better designed space would bedesirable. There is one set of rooms in the ED which is not easily kept under observation. The staff membersare aware of this and keep only the lowest risk patients in these rooms. Clients presenting as potentiallyinfectious are isolated appropriately.


The emergency (ED) team is made up of fully qualified medical personnel. There are well-defined positionsand position profiles. Team members receive appropriate training and orientation. Ongoing continuingtraining is provided and documented. Workload and division of labour is under continual reassessment withappropriate modification. Staff members are encouraged to give their feedback, and performance reviewsare carried out and documented.

There is timely access to specialists, especially pediatricians. Although there is no pediatric service at SMGH,children are often seen in the emergency department, and attended to, and if admission is required they aresent or transported to another hospital after stabilizing them for transfer.


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There is timely access to specialists, especially pediatricians. Although there is no pediatric service at SMGH,children are often seen in the emergency department, and attended to, and if admission is required they aresent or transported to another hospital after stabilizing them for transfer.


St. Mary’s General Hospital's emergency department (ED) is well-marked and directs patients and theirfamilies to an entrance where security is visible, and signage directs them to a qualified trained triage nurse.The triage nurse performs a comprehensive evaluation of the complaint that has brought them to the ED withassociated history. Family members are encouraged to contribute and collaborate additional information.

The patient is assessed using the standard Canadian Triage Acuity Scale (CTAS) scoring system thatdetermines acuity and based on the score, the patient is either placed immediately, or if stable enough isasked to wait in the waiting room. If the latter occurs, ongoing assessment is made frequently for change incondition. Once a bed space is available, the patient is placed and admitted by a registered nurse and thenurse will continue to observe, and treat in collaboration with the rest of the team members. The team hasaccess to 24/7 diagnostics and pharmacy and a geriatric emergency specialist for further review of selectpatients.

Interviews with patients reflected a common sentiment that care is respectful, individualized and that theyare kept apprised of their care trajectory in a timely manner. Approximately 10% of total patients seen in theED are pediatric. The staff members receive orientation and education annually in both adult and pediatricresuscitation. There are standardized clinical practice guidelines to direct practice. The leadership isanticipating the hiring of a clinical pharmacist that will augment the team complement.

When the patient is transferred in-house or to another agency or discharged home, the nurse or respectiveteam member(s) will go over the discharge instructions and ensure the patient is comfortable with their carefollowing their discharge. This ED team is hard working, approachable and knowledgeable and their patientsappreciate the care, attitude and respect that is afforded them during their stay in this department.


Client records are accurate, current and available to appropriate personnel and are secured againstunauthorized access. Technology is current and staff members are up to date on its use. Best practiceguidelines are used. The medical records are almost completely digitalized, and staff members areappropriately instructed in the technology.


A falls prevention strategy is in place, in that clients at risk are identified. A more complete falls preventionstrategy will be implemented in a few months time. There are regular safety briefings and sentinel andadverse events are monitored, documented, and corrective steps are taken.

A good quality improvement program is in place, with careful monitoring of several different parameters andimprovement programs planned based on the quality improvement findings.


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occurs in the intensive care unit (ICU). The staff members are fully conversant with the protocols involved,and receive training in organ donation procedures.



Organ and tissue donation is sometimes initiated in the emergency department (ED), but most of this activity

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3.2.6 Standards Set: Infection Prevention and Control Standards


Priority Process: Infection Prevention and Control



Priority Process: Infection Prevention and Control

The infection prevention and control (IPAC) service at St. Mary's General Hospital (SMGH) is delivered by ahighly engaged and committed team of infection control practitioners and a physician advisor that supportsboth SMGH and the Grand River Hospital. There is a joint SMGH/Grand River Hospital IPAC committee inplace.

The SMGH IPAC team is also a member of a regional IPAC forum across the Local Health Integrated Network(LHIN). Evidence-based global and provincial best practice guidelines inform the organization's IPAC policiesand protocols including surveillance, training on isolation precautions, auditing, and monitoring. An ambitiousannual work plan has been developed for the current fiscal year; the team is encouraged to develop metricswith targets for the actions (action plans) that will permit monitoring of progress over time and also theimpact on the outcomes of goals.

The IPAC indicators are publicly reported on the SMGH external website. The rates of Clostridium-difficile,vancomycin resistant enterococci (VRE), methicillin resistant staphylococcus aureus (MRSA), andhand-hygiene compliance/audit rates, central line infection (CLI) rates, and ventilator associated pneumoniarates, all are posted for viewing. It is noted that all rates are below the posted benchmark. Hand-hygienecompliance rates show variation over time. A project that tested inter-rater reliability showed little variationin ratings when hand-hygiene compliance was assessed by a familiar or unfamiliar rater. The IPAC team hasplans to continue its vigilance in monitoring and promoting hand-hygiene compliance and will use a dedicatedvolunteer that will personally meet with newly admitted patients to promote both understanding andcompliance with their own hand hygiene, as well as understanding of organizational expectations forhand-hygiene compliance on care providers. The goal is to empower patients to take an active role in theirown safety. The IPAC team is encouraged to create an evaluation framework and metrics for this initiativeand, if results warrant, to submit the initiative to Accreditation Canada for consideration as a leadingpractice.

The IPAC team fulfils an important role in assisting the organization to address the bio-burden risksassociated with its aging infrastructure. Examples include: replacement of all fabric chairs in patient careareas with chairs that have wipe-able surfaces; removal of wooden railings in patient care areas; andinstallation of wipe-able window blinds to replace fabric curtains.

The IPAC team is involved in the planning and designing of changes to the physical environment, includingplanning for construction and renovations. The team is also a resource to other departments, such asmaintenance, medical devices reprocessing, and housekeeping to ensure adherence to infection controlpractices. A new system for management of human waste has been implemented, and it includes the use offlusher disinfectors for commodes and bedpans and the use of Hygie-bags facility-wide in an effort to reduce

It is clear in discussing IPAC issues with staff members and physicians, as well as with patients and familiesthat there is a good awareness of IPAC practices. Staff members across the organization are aware of thefocus on hand hygiene, but were typically unable to describe their unit's compliance rate. Information isposted on the SMGH intranet site, as well as on the external website. Clinical staff members and leadersquestioned during the on-site tracers reported that they do not routinely "pull" this information for reviewand were unable to cite their unit level compliance rates. The organization is encouraged to test whether thebehaviours that are being targeted for improvement would improve if staff members were given ready accessto their unit level compliance rates. Patients and family members questioned during the tracers reportedhaving been made aware of the importance of hand hygiene.

Many of the rooms in the hospital are of older design, presenting geo-spatial limitations when placing patientsrelative to current provincial standards. Satisfactory IPAC practices were evidenced in spite of: constraints ofsmall spaces; limited storage; three or four patients to a room; shared bathrooms and limited availability ofsinks for handwashing. The IPAC team and organization is encouraged to review the extent to which hangingand potted plants and other items on window ledges are present in the clinical areas, including the criticalcare areas.

The IPAC team provides education and training on IPAC to all new staff. An example of an initiative thataligns to the SMGH strategic priority of: "reaching beyond our walls" is the communication of patientantibiotic resistant organism (ARO) status to community-based family physicians in an effort to preventexposures by allowing isolation precautions to be implemented in facilities where the patient may bereferred.

As a result of a cost benefit analysis conducted by the SMGH IPAC team, antimicrobial coated, recyclablecurtains have been installed in patient rooms. Traditional hospital curtains have the potential to becomesources of pathogenic transmission, as hospital acquired infections (HAIs) can remain on the curtain’s surfacefor long periods. Microbiology testing of curtains hung in the emergency department (ED) as a trial at threeand six months was arranged by the SMGH IPAC team before installing the curtains facility-wide. The curtainsare fitted with heat-sealed self-auditing labels, showing the date of installation. Reducing the frequency ofcurtain replacement has been associated with reduced musculoskeletal injuries of housekeeping staff. Thecurtains are bio-degradable when disposed, and reduce laundry costs, as well as staff time and costs tochange the curtains.

The IPAC team is congratulated on the implementation of an antimicrobial stewardship program in 2013 thatresulted in an overall reduction of antimicrobial use and annual savings of $35K. The IPAC surveillancesoftware 'ICNet' that will link to Meditech is currently in the final stages of implementation, and is expectedto provide further opportunities for this team to promote best practices in antimicrobial stewardship.


staff exposures to body fluids.

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It is clear in discussing IPAC issues with staff members and physicians, as well as with patients and familiesthat there is a good awareness of IPAC practices. Staff members across the organization are aware of thefocus on hand hygiene, but were typically unable to describe their unit's compliance rate. Information isposted on the SMGH intranet site, as well as on the external website. Clinical staff members and leadersquestioned during the on-site tracers reported that they do not routinely "pull" this information for reviewand were unable to cite their unit level compliance rates. The organization is encouraged to test whether thebehaviours that are being targeted for improvement would improve if staff members were given ready accessto their unit level compliance rates. Patients and family members questioned during the tracers reportedhaving been made aware of the importance of hand hygiene.

Many of the rooms in the hospital are of older design, presenting geo-spatial limitations when placing patientsrelative to current provincial standards. Satisfactory IPAC practices were evidenced in spite of: constraints ofsmall spaces; limited storage; three or four patients to a room; shared bathrooms and limited availability ofsinks for handwashing. The IPAC team and organization is encouraged to review the extent to which hangingand potted plants and other items on window ledges are present in the clinical areas, including the criticalcare areas.

The IPAC team provides education and training on IPAC to all new staff. An example of an initiative thataligns to the SMGH strategic priority of: "reaching beyond our walls" is the communication of patientantibiotic resistant organism (ARO) status to community-based family physicians in an effort to preventexposures by allowing isolation precautions to be implemented in facilities where the patient may bereferred.

As a result of a cost benefit analysis conducted by the SMGH IPAC team, antimicrobial coated, recyclablecurtains have been installed in patient rooms. Traditional hospital curtains have the potential to becomesources of pathogenic transmission, as hospital acquired infections (HAIs) can remain on the curtain’s surfacefor long periods. Microbiology testing of curtains hung in the emergency department (ED) as a trial at threeand six months was arranged by the SMGH IPAC team before installing the curtains facility-wide. The curtainsare fitted with heat-sealed self-auditing labels, showing the date of installation. Reducing the frequency ofcurtain replacement has been associated with reduced musculoskeletal injuries of housekeeping staff. Thecurtains are bio-degradable when disposed, and reduce laundry costs, as well as staff time and costs tochange the curtains.

The IPAC team is congratulated on the implementation of an antimicrobial stewardship program in 2013 thatresulted in an overall reduction of antimicrobial use and annual savings of $35K. The IPAC surveillancesoftware 'ICNet' that will link to Meditech is currently in the final stages of implementation, and is expectedto provide further opportunities for this team to promote best practices in antimicrobial stewardship.


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3.2.7 Standards Set: Medication Management Standards


Priority Process: Medication Management

The organization stores chemotherapy medications in a separate negativepressure room with adequate ventilation segregated from other supplies.

13.3


Priority Process: Medication Management

St. Mary's General Hospital (SMGH) pharmacy is an in-patient pharmacy only. Out-patient prescriptions aresent to community pharmacies. This allows orders written by a physician on the unit to be dispensed by apharmacist that is attached to the unit. Prescribing is done by written order, while the prescription isdispensed digitally. This goes smoothly, and the mix of modalities does not cause any problems.

Pyxis pharmacy dispensing systems are used in all patient areas. Staff satisfaction with this system is high,and the system works safely, securely and efficiently.

The pharmacy was displaced from its basement location to the eighth floor by the flood in February 2015. Ithas just moved back to its original location, and is still settling in but this has gone smoothly with nodisruption of services. All physical parameters are up to standards except for a lack of positive pressure airflow in the area where chemotherapy medications are stored.

The SMGH is a cardiac surgery facility and as such, it needs to have certain unusual drugs to be available,outside of the usual standards of Accreditation Canada. The SMGH has drug variances for heparin, certainelectrolytes and opioids. These are all duly documented and rationalized.

The pharmacy is run by a medication and therapeutics committee and a pharmacy committee. Regularmeetings are held and minutes are kept. There are appropriate connections to medical administration.


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3.2.8 Standards Set: Medicine Services





Team members have position profiles that define roles, responsibilities, andscope of practice.

3.2


Following transition or end of service, the team contacts clients, families,or referral organizations to evaluate the effectiveness of the transition, anduses this information to improve its transition and end of service planning.

11.6







Three medicine units were surveyed namely: the chest unit, cardiology and general medicine. Staff memberswere engaged, enthusiastic, and conveyed compassion and commitment to their patients. The patients andfamilies interviewed were appreciative, felt safe, had information to make informed decisions andcomplimented their care providers. They had some observations regarding parking and way-finding anddescribed volunteers as excellent in terms of guiding them or it would be difficult, and also food quality.

During the on-site tracers there was evidence of process improvement program (PIP) or discharge actionrounds on each of the units, and this was occurring in an interdisciplinary way. In addition, daily huddles toreview length of stay (LOS) performance for cardiology - congestive heart failure (CHF) patients, staffsatisfaction rates for the chest unit and daily falls rates (all) were evidenced. The staff members participatedon behalf of their patients. Also evident was the commitment to continuous quality improvement and makinga difference.


Team space is available for the inter-professional team members to spend time in their areas of work andhave space to collaborate with the rest of the team.

Orientation to the units depends on the experience and education of the newly hired staff. Annualcertifications to maintain competency of skills including delegated medical acts (cardiology) was described.In addition on cardiology, one of the 'watch' metrics was to increase the number of full-flex (cross-trained)staff. The goal is two staff members per month. This will ensure more staffing to provide care for patientsshould an area become short staffed.

New Baxter smart pumps were recently implemented across the organization. All registered nurses (RNs) andregistered practical nurses (RPNs) received training in how to use the intravenous (IV) and epidural pumps.

Team roles are defined however on clarification and discussion with staff members on the various medicineunits, they described that they are not working at full scope of practice. The organization has opted tocontinue to centralize services for example, the IV team which does not allow or enable the RN's and RPN's towork at full scope. In addition, the role of RPN is not fully utilized in the organization.


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Orientation to the units depends on the experience and education of the newly hired staff. Annualcertifications to maintain competency of skills including delegated medical acts (cardiology) was described.In addition on cardiology, one of the 'watch' metrics was to increase the number of full-flex (cross-trained)staff. The goal is two staff members per month. This will ensure more staffing to provide care for patientsshould an area become short staffed.

New Baxter smart pumps were recently implemented across the organization. All registered nurses (RNs) andregistered practical nurses (RPNs) received training in how to use the intravenous (IV) and epidural pumps.

Team roles are defined however on clarification and discussion with staff members on the various medicineunits, they described that they are not working at full scope of practice. The organization has opted tocontinue to centralize services for example, the IV team which does not allow or enable the RN's and RPN's towork at full scope. In addition, the role of RPN is not fully utilized in the organization.


Excellence in quality of care and patient safety is a focus for all the medicine units visited during the survey.Patients provided feedback that they were kept well informed, respected and responded to in a timely waywhen requiring care.

There is a quality of life room on the fifth floor (General medicine) to respect the needs of palliative patientsand their families.

Process improvement program (PIP) discharge action rounds are held daily, with a plan of care that all staffmembers were aware of and contributed to while addressing patient goals, and this interaction was inevidence. Communication boards in patients rooms highlight the providers for the day and colour-codedprogress to discharge. In addition there was evidence of admission and ongoing assessment tools including forpain, and use of the Braden scale, venous thrombo embolism (VTE) prophylaxis and falls risk assessmenttools.

Note is made of the updated tool for staff members to use and for a standardized approach using thesituation, background, assessment, request/recommendations (SBAR) format to communicate patient-specificinformation when transferring care of a patient between or among providers, and when communicatingconcerns for which an intervention is being sought.

At end-of-service or transition including discharge the individual teams do not contact patients/families asfollow-up to evaluate the effectiveness of the transition. Such a process can yield information to improve endof service planning and transitions. There is a plan to implement organization wide, real-time patientsatisfaction surveys to provide staff members with proactive information to improve the overall experience.The current process involves utilizing the NRC Picker surveys for the emergency department and in-patients.


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and process improvements.


Daily huddles occur on each of the medicine units and there is evidence of achievements towards the drivermetric of daily evaluation of falls, with a focus on improving this outcome for patients.

The emergency department (ED) length of stay (LOS) for at least 90% of admitted patients has a reductiontarget of 25%, and is an in-patient target. However, this focus was not evidenced on the units visited. Movingtowards collaborative projects that support this philosophy is recommended.

TheConnect the DOTS program for patients and families has been communicated across the organization. Thisfocus on self-care and questions that require to be addressed on discharge is an innovative way to ensurecompliance and safety on discharge.



Currently, the documentation is partially paper and partially electronic and this can pose a challenge forproviders to access all the information they require.

Research in the organization follows a standardized approach for approval.

The team has adequate information in the form of a scorecard to know how well it is doing for both outcomes

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3.2.9 Standards Set: Organ and Tissue Donation Standards for DeceasedDonors
















Organ donation is a part of the overall strategy at SMGH. Policies are in place for both cardiac deaths andneurological deaths. There is a strong affiliation with the Trillium Gift of Life Network (TGLN), but no writtenagreement. There is an organ and tissue donation committee. There is adequate access to facilities,technology and staff. There is a standard operating procedure (SOP) manual which addresses all aspects ofthe organization. This is actually a TGLN manual, but fully adopted by SMGH. Many of the points covered inthis review of standards are applicable to SMGH only through its close affiliation with TGLN.


The donation team is a well-balanced group of physicians, nurses and allied health personnel. The teamregularly self-evaluates and will make changes accordingly. The donation coordinator is a registered nurse,specially trained for the position. The coordinator is based at the Trillium Gift of Life Network, but worksclosely with the SMGH staff. The coordinator is available at all times, and can arrive within a few hours atshort notice. Team members have regular performance evaluations.


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A standardized questionnaire is used to assess all donors.


The donor records are accurate, current, readily available to authorized personnel, but confidential andimpervious to unauthorized access. There are a set of guidelines which are followed, both at the local andprovincial levels. These are reviewed for currency and best practice. Research is not done at the local orprovincial level on donor procedures, but is done at the provincial level on transplantation procedures.


Safety issues and sources of risk are identified and monitored. Quality is a priority, and areas are identifiedfor quality improvement. Quality improvement information is shared with stakeholders.


Family sensitivities and the wishes of the donor are respected. Appropriate counselling and ethical support isavailable. Screening of donors is done by testing in the on-site laboratory, or is sent out to the Trilliumlaboratory. The donors are properly managed and maintained from the declaration of death up until the timeof actual donation.

Demarcation of responsibilities between pre-donor status and definitive donor status are clearly drawn. Therecovery team safely, efficiently and respectfully removes the organs. There is follow-up communication withthe family but the identities of donor and recipient are confidential.


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3.2.10 Standards Set: Point-of-Care Testing


Priority Process: Point-of-care Testing Services



Priority Process: Point-of-care Testing Services

Point-of-Care Testing (POCT) has been in situ at St. Mary's General Hospital (SMGH) since 2003 with additionaltests added every year. The POCT testing compliance for users is monitored by annual testing monitoring andreported. If annual competency testing is not done by individual practitioners, as a safety mechanism theyare locked out and cannot use the equipment thus, forcing recertification.

Test results can be retrieved form the laboratory main unit to prevent loss of results. Test results outside ofnormal parameters are responded to with a verbal call-back from laboratory staff.


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3.2.11 Standards Set: Transfusion Services


Priority Process: Transfusion Services



Priority Process: Transfusion Services

The organization's transfusion services serve the cardiac and respiratory surgical programs, as well as variedsurgical procedures, cardiac interventional procedure and critical patient care in the cardiovascular andmed-surg intensive care units and a variety of other patient populations in need of blood.

At any one time the transfusion service has on hand 100 plus units of blood as well as additional bloodproducts required to serve its patients. Canadian blood services (CBS) has awarded St. Mary's GeneralHospital's transfusion service a distinction award. The award is for innovating a method of monitoring andensuring use of the blood products before expiry date by partnering with Grand River Hospital to use theblood on its surgical patients thus, ensuring use of a precious resource.

Blood products are available following a full cross and screen within 45-50 minutes however, in emergencysituations uncrossed blood can be available within 8-10 minutes. The organization has also developed aMassive Transfusion Policy that allows for a pathology consult to assist in determining the blood-to-bloodproducts ratio required to ensure optimum volume resuscitation.

Blood administration follows a rigorous patient identification using the hospital policy of two identifiers forpatient identification as well as the CBS required unit of blood identification checks. All blood products aretemperature controlled in units that have back-up mechanism in case of power failure. Standard operatingprocedure (SOP) policies exist for transfusion reaction, which is graded from mild to severe with associatedtreatment requirements, as well as full investigation of the incident.


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3.2.12 Priority Process: Surgical Procedures

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



The operating rooms (ORs) are well-maintained, spacious and well managed. The main focus of surgery iscardio thoracic. Other specialties such as general surgery, urology, minor orthopaedics and otolaryngology(ENT) are also accommodated. There is a large out-patient facility at St. Mary's General Hospital. Pediatricsurgery is not done. The standards of management are fully met. The cardiac catheterization unit and theseparate cardiovascular surgery recovery area were also reviewed. All risk factors are accounted for andpreventive measures are used.

A multidisciplinary team manages the OR unit. The patient pre-operative, surgical pause and post-operativecheck routines are done flawlessly. The compliance with this is good, but could be better, and steps arebeing applied to further improve.

Many different quality issues are addressed and aided by an involved staff. Staff members take an active partin the quality improvement (QI) initiatives. All staff credentials and training and retraining protocols areappropriate.

Record keeping and charting is of high standard however, the slow movement toward completely digitalizingthe information system is creating frustration for staff.

Pre-operative, intra-operative and post-operative routines and patient care are of a high standard ofprofessionalism. Overall, the surgical unit and its staff and management were found to be excellent.


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Instrument ResultsSection 4

As part of Qmentum, organizations administer instruments. Qmentum includes three instruments (orquestionnaires) that measure governance functioning, patient safety culture, and quality of worklife. They arecompleted by a representative sample of clients, staff, senior leaders, board members, and otherstakeholders.

4.1 Governance Functioning Tool

The Governance Functioning Tool enables members of the governing body to assess board structures andprocesses, provide their perceptions and opinions, and identify priorities for action. It does this by askingquestions about:

• Board composition and membership• Scope of authority (roles and responsibilities)• Meeting processes• Evaluation of performance

Accreditation Canada provided the organization with detailed results from its Governance Functioning Tool priorto the on-site survey through the client organization portal. The organization then had the opportunity to addresschallenging areas.

• Data collection period: June 22, 2014 to July 31, 2014

• Number of responses: 11

Governance Functioning Tool Results

% Disagree % Neutral % Agree

Organization Organization Organization

* CanadianAverage

%Agree

1 We regularly review, understand, and ensurecompliance with applicable laws, legislation andregulations.

0 27 73 93

2 Governance policies and procedures that define ourrole and responsibilities are well-documented andconsistently followed.

0 0 100 95

3 We have sub-committees that have clearly-definedroles and responsibilities.

0 9 91 97

4 Our roles and responsibilities are clearly identifiedand distinguished from those delegated to the CEOand/or senior management. We do not becomeoverly involved in management issues.

0 0 100 95

5 We each receive orientation that helps us tounderstand the organization and its issues, andsupports high-quality decisionmaking.

0 0 100 92

Instrument Results 57Accreditation Report

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* CanadianAverage

%Agree

6 Disagreements are viewed as a search for solutionsrather than a “win/lose”.

0 9 91 95

7 Our meetings are held frequently enough to makesure we are able to make timely decisions.

0 0 100 98

8 Individual members understand and carry out theirlegal duties, roles and responsibilities, includingsub-committee work (as applicable).

0 10 90 96

9 Members come to meetings prepared to engage inmeaningful discussion and thoughtfuldecision-making.

0 9 91 94

10 Our governance processes make sure that everyoneparticipates in decision-making.

9 18 73 94

11 Individual members are actively involved inpolicy-making and strategic planning.

9 36 55 89

12 The composition of our governing body contributesto high governance and leadership performance.

0 0 100 93

13 Our governing body’s dynamics enable groupdialogue and discussion. Individual members ask forand listen to one another’s ideas and input.

0 0 100 96

14 Our ongoing education and professional developmentis encouraged.

0 0 100 88

15 Working relationships among individual members andcommittees are positive.

0 0 100 97

16 We have a process to set bylaws and corporatepolicies.

0 9 91 95

17 Our bylaws and corporate policies coverconfidentiality and conflict of interest.

0 0 100 97

18 We formally evaluate our own performance on aregular basis.

0 18 82 82

19 We benchmark our performance against othersimilar organizations and/or national standards.

0 27 73 72

20 Contributions of individual members are reviewedregularly.

0 27 73 64


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* CanadianAverage

%Agree

21 As a team, we regularly review how we functiontogether and how our governance processes could beimproved.

0 18 82 81

22 There is a process for improving individualeffectiveness when non-performance is an issue.

0 40 60 64

23 We regularly identify areas for improvement andengage in our own quality improvement activities.

0 18 82 80

24 As a governing body, we annually release a formalstatement of our achievements that is shared withthe organization’s staff as well as external partnersand the community.

9 45 45 84

25 As individual members, we receive adequatefeedback about our contribution to the governingbody.

9 55 36 69

26 Our chair has clear roles and responsibilities andruns the governing body effectively.

0 0 100 96

27 We receive ongoing education on how to interpretinformation on quality and patient safetyperformance.

9 18 73 84

28 As a governing body, we oversee the development ofthe organization's strategic plan.

0 9 91 95

29 As a governing body, we hear stories about clientsthat experienced harm during care.

0 0 100 85

30 The performance measures we track as a governingbody give us a good understanding of organizationalperformance.

0 18 82 92

31 We actively recruit, recommend and/or select newmembers based on needs for particular skills,background, and experience.

0 9 91 87

32 We have explicit criteria to recruit and select newmembers.

0 20 80 84

33 Our renewal cycle is appropriately managed toensure continuity on the governing body.

0 0 100 90


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* CanadianAverage

%Agree

34 The composition of our governing body allows us tomeet stakeholder and community needs.

0 9 91 94

35 Clear written policies define term lengths and limitsfor individual members, as well as compensation.

0 18 82 94

36 We review our own structure, including size andsubcommittee structure.

9 18 73 89

37 We have a process to elect or appoint our chair. 9 9 82 95

*Canadian average: Percentage of Accreditation Canada client organizations that completed the instrumentfrom July to December, 2014 and agreed with the instrument items.


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4.2 Canadian Patient Safety Culture Survey Tool

Organizational culture is widely recognized as a significant driver in changing behavior and expectations in orderto increase safety within organizations. A key step in this process is the ability to measure the presence anddegree of safety culture. This is why Accreditation Canada provides organizations with the Patient Safety CultureTool, an evidence-informed questionnaire that provides insight into staff perceptions of patient safety. This toolgives organizations an overall patient safety grade and measures a number of dimensions of patient safetyculture.

Results from the Patient Safety Culture Tool allow the organization to identify strengths and areas forimprovement in a number of areas related to patient safety and worklife.

Accreditation Canada provided the organization with detailed results from its Patient Safety Culture Tool prior tothe on-site survey through the client organization portal. The organization then had the opportunity to addressareas for improvement. During the on-site survey, surveyors reviewed progress made in those areas.

• Data collection period: June 2, 2014 to August 31, 2014

• Number of responses: 305

• Minimum responses rate (based on the number of eligible employees): 283


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0

10

20

30

40

50

60

70

80

90

100

Perc

enta

ge

Posi

tive

(%)

Organizational(senior)

leadershipsupport for

safety

Unit learningculture

Supervisoryleadership for

safety

Enabling OpenCommunicatio

n I:judgment-freeenvironment

Enabling OpenCommunicatio

n II: jobrepercussions

of error

61%

Incidentfollow up

Stand-aloneitems

69% 74% 58% 39% 69% 52%

67% 65% 77% 55% 33% 69% 64%

*Canadian average: Percentage of Accreditation Canada client organizations that completed the instrumentfrom July to December, 2014 and agreed with the instrument items.

OverallPerceptions ofClient Safety

62%

66%

* Canadian Average

St. Mary's General Hospital, Kitchener

Legend

Canadian Patient Safety Culture Survey Tool: Results by Patient Safety Culture Dimension


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4.3 Worklife Pulse

Accreditation Canada helps organizations create high quality workplaces that support workforce wellbeing andperformance. This is why Accreditation Canada provides organizations with the Worklife Pulse Tool, anevidence-informed questionnaire that takes a snapshot of the quality of worklife.

Organizations can use results from the Worklife Pulse Tool to identify strengths and gaps in the quality ofworklife, engage stakeholders in discussions of opportunities for improvement, plan interventions to improve thequality of worklife and develop a clearer understanding of how quality of worklife influences the organization'scapacity to meet its strategic goals. By taking action to improve the determinants of worklife measured in theWorklife Pulse tool, organizations can improve outcomes.

The organization used an approved substitute tool for measuring quality of Worklife. The organization hasprovided Accreditation Canada with results from its substitute tool and had the opportunity to identify strengthsand address areas for improvement. During the on-site survey, surveyors reviewed actions the organization hastaken.


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Measuring client experience in a consistent, formal way provides organizations with information they

can use to enhance client-centred services, increase client engagement, and inform quality

improvement initiatives.

Prior to the on-site survey, the organization conducted a client experience survey that addressed the

following dimensions:

Respecting client values, expressed needs and preferences,including respecting client rights,

cultural values, and preferences; ensuring informed consent and shared decision-making; and

encouraging active participation in care planning and service delivery.

Sharing information, communication, and education,including providing the information that

people want, ensuring open and transparent communication, and educating clients and their

families about the health issues.

Coordinating and integrating services across boundaries,including accessing services,

providing continuous service across the continuum, and preparing clients for discharge or

transition.

Enhancing quality of life in the care environment and in activities of daily living,including

providing physical comfort, pain management, and emotional and spiritual support and

counselling.

The organization then had the chance to address opportunities for improvement and discuss related

initiatives with surveyors during the on-site survey.

4.4 Client Experience Tool

Client Experience Program Requirement

Conducted a client experience survey using a survey tool and approach thatmeets accreditation program requirements

Met

Provided a client experience survey report(s) to Accreditation Canada Met


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Organization's CommentarySection 5

After the on-site survey, the organization was invited provide comments to be included in thisreport about its experience with Qmentum and the accreditation process.

Accreditation Canada surveyors visited St. Mary's General Hospital between June 21st and June 25th,2015. During the onsite survey, the Surveyors noted that they were very impressed by the culture andcommitment of all at St. Mary’s staff. In the lead Surveyor's words, "this was a very successful survey.You should be extremely proud."

In 2011, when we were granted exemplary status, we had four unmet Required Organizational Practices(ROPs) and 26 unmet criteria for a score of 98.5%. In the 2015 survey, they evaluated 1,877 criteria withonly one unmet ROP and 12 unmet criteria for a score of 99.4% - an "exceptional" rate, according to theSurveyors.

Some of our successes, highlighted during the onsite survey include:

• We have engaged, committed, compassionate staff, physicians and volunteers and a transparent andopen leadership team.• We have a culture of continuous quality improvement and our success with the Lean ManagementSystem is showing "tremendous sustainability." Staff across the organization, as well as board members,are actively using the tools and processes to improve quality and safety, the patient and familyexperience, and quality of work life.• We are consistently one of the safest hospitals in Canada, with low HSMR (Hospital StandardizedMortality Ratio) scores. We have made significant improvements in medication reconciliation, antibioticstewardship, implementation of a best possible medication history (BPMH) on all units and introductionof antimicrobial curtains to reduce hospital acquired infections. Medication reconciliation will continueto be a significant focus with additional standards to be met during our next Accreditation.• Our Laboratory met 100% of Ontario Laboratory Accreditation standards in its own Accreditationearlier this week.• The commitment to our Strategic Plan is clearly evident in many areas including our focus on staffsafety as demonstrated by the introduction of our new security services and our targets for reducingmusculoskeletal injuries and blood and body fluid exposures. We are also focused on reaching beyondour walls, an example of which is our innovative remote pacemaker monitoring service for patients inthe Guelph area.• We have made improvements in our emergency preparedness, particularly following our 2015 floodand our successes should be shared with others. The surveyors were impressed with our response to theflood, including the timely communication and update to the community during the event.• Our patients and staff benefit from the significant presence and role of our volunteers, who are veryresponsive, committed and attentive to patients.• We have been recognized as one of the top 15 employers in Waterloo Region.• Other areas of strength include excellent relationships with our community partners and exceptional24/7 access to Ethics consultation services through our partners at St. Joseph's Healthcare Hamilton.

St. Mary’s recognizes the challenges we face as an Acute Care Hospital in a growing community. Thesechallenges were echoed during the survey process, and include:• Physical Facility- The non-renovated portion of facility is aging and there is a need for additional spaceto support Cardiac Arrhythmia• Human Resources Development- We will continue to focus on leadership development accompanied byformal succession plans for key leadership roles at St. Mary’s.

for work on implementing a Falls Prevention Program. This was the one Required Organizational Practicethat the surveyors felt remained unmet. St. Mary's General Hospital has developed falls prevention plansfor outpatient services is committed to addressing the gaps in preventing falls within our AmbulatoryCare and Diagnostic Imaging services. Organization's Commentary 65Accreditation Report

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for work on implementing a Falls Prevention Program. This was the one Required Organizational Practicethat the surveyors felt remained unmet. St. Mary's General Hospital has developed falls prevention plansfor outpatient services is committed to addressing the gaps in preventing falls within our AmbulatoryCare and Diagnostic Imaging services.

Organization's Commentary 66Accreditation Report

The on-site survey revealed an opportunity in the Ambulatory Care Services and Diagnostic Imaging areas

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QmentumAppendix A

Health care accreditation contributes to quality improvement and patient safety by enabling a healthorganization to regularly and consistently assess and improve its services. Accreditation Canada's Qmentumaccreditation program offers a customized process aligned with each client organization's needs and priorities.

As part of the Qmentum accreditation process, client organizations complete self-assessment questionnaires,submit performance measure data, and undergo an on-site survey during which trained peer surveyors assess theirservices against national standards. The surveyor team provides preliminary results to the organization at the endof the on-site survey. Accreditation Canada reviews these results and issues the Accreditation Report within 10business days.

An important adjunct to the Accreditation Report is the online Quality Performance Roadmap, available to clientorganizations through their portal. The organization uses the information in the Roadmap in conjunction with theAccreditation Report to ensure that it develops comprehensive action plans.

Throughout the four-year cycle, Accreditation Canada provides ongoing liaison and support to help theorganization address issues, develop action plans, and monitor progress.

Following the on-site survey, the organization uses the information in its Accreditation Report and QualityPerformance Roadmap to develop action plans to address areas identified as needing improvement. Theorganization provides Accreditation Canada with evidence of the actions it has taken to address these requiredfollow ups.

Five months after the on-site survey, Accreditation Canada evaluates the evidence submitted by the organization.If the evidence shows that a sufficient percentage of previously unmet criteria are now met, a new accreditationdecision that reflects the organization's progress may be issued.

Evidence Review and Ongoing Improvement

Action Planning

Qmentum 67Accreditation Report

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Priority ProcessesAppendix B

Priority processes associated with system-wide standards

Priority Process Description

Communication Communicating effectively at all levels of the organization and with externalstakeholders

Emergency Preparedness Planning for and managing emergencies, disasters, or other aspects of publicsafety

Governance Meeting the demands for excellence in governance practice.

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

Integrated QualityManagement

Using a proactive, systematic, and ongoing process to manage and integratequality and achieve organizational goals and objectives

Medical Devices andEquipment

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

Patient Flow Assessing the smooth and timely movement of clients and families throughservice settings

Physical Environment Providing appropriate and safe structures and facilities to achieve theorganization's mission, vision, and goals

Planning and Service Design Developing and implementing infrastructure, programs, and services to meetthe needs of the populations and communities served

Principle-based Care andDecision Making

Identifying and decision making regarding ethical dilemmas and problems.

Resource Management Monitoring, administration, and integration of activities involved with theappropriate allocation and use of resources.

Priority processes associated with population-specific standards


Chronic Disease Management Integrating and coordinating services across the continuum of care forpopulations with chronic conditions

Population Health andWellness

Promoting and protecting the health of the populations and communitiesserved, through leadership, partnership, innovation, and action.

Priority Processes 68Accreditation Report

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Priority processes associated with service excellence standards


Blood Services Handling blood and blood components safely, including donor selection, bloodcollection, and transfusions

Clinical Leadership Providing leadership and overall goals and direction to the team of peopleproviding services.

Competency Developing a skilled, knowledgeable, interdisciplinary team that can manageand deliver effective programs and services

Decision Support Using information, research, data, and technology to support managementand clinical decision making

Diagnostic Services: Imaging Ensuring the availability of diagnostic imaging services to assist medicalprofessionals in diagnosing and monitoring health conditions

Diagnostic Services:Laboratory

Ensuring the availability of laboratory services to assist medical professionalsin diagnosing and monitoring health conditions

Episode of Care Providing clients with coordinated services from their first encounter with ahealth care provider through their last contact related to their health issue

Impact on Outcomes Identifying and monitoring process and outcome measures to evaluate andimprove service quality and client outcomes

Infection Prevention andControl

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

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 potential donors, approaching families, and recoveringorgans

Organ and Tissue Transplant Providing organ transplant services, from initial assessment of transplantcandidates to providing follow-up care to recipients

Organ Donation (Living) Providing organ donation services for living donors, including supportingpotential donors to make informed decisions, conducting donor suitabilitytesting, and carrying out donation procedures

Point-of-care TestingServices

Using non-laboratory tests delivered at the point of care to determine thepresence of health problems


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Primary Care ClinicalEncounter

Providing primary care in the clinical setting, including making primary careservices accessible, completing the encounter, and coordinating services

Public Health Maintaining and improving the health of the population by supporting andimplementing policies and practices to prevent disease, and assess, protect,and promote health.

Surgical Procedures Delivering safe surgical care, including preoperative preparation, operatingroom procedures, postoperative recovery, and discharge


Documents

St. Mary's General Hospital, Kitchener · Accreditation Report St. Mary's General Hospital, Kitchener On-site survey dates: June 21, 2015 - June 25, 2015 Accredited by ISQua Kitchener,