Debriefing Presentation Covenant Health October 15-20, 2017 Accredited by

Surveyor Team David Keselman Marilyn Barrett (Team Leader)

Overview of Survey Process # of Priority Processes: 5 # of Sites: 10

This is a calling, not a job! (Physician)

Highlights Since Last Survey Successes: Med Rec well embedded into practice ROPs being met; maintaining high compliance rate Resident & Family Councils active Challenges: Turnover and recruitment challenges in middle management Ability to integrate information technology (hybrid charts, multiple systems that do not talk to each other) Large span of control and impacts on operational deliverables (e.g. PA’s, Audits, Monitoring)

Overall Observations Strengths: Dedicated staff/leaders High levels of teamwork and inter-professional collaboration Resident/Family councils active Areas of high satisfaction Volunteers

Overall Observations Challenges: Recruitment & Retention of qualified staff and leaders, particularly in more rural areas Lean support to leaders (e.g. Clinical Education, OH&S, HR, etc.) Communication: inconsistency in mode of communication and information transfer (at sites and in between sites) Aging Infrastucture in some sites

Overview by Quality Dimension Met Unmet N/A Total Accessibility 15 1 16 Appropriateness 109 7 116 Client-centred Services 90 4 94 Continuity Efficiency 2 Population Focus Safety 53 55 Worklife 3 18

Overview by Standard Section Met Unmet N/A Total Hospice, Palliative, End-of-Life Services 152 7 159 Long Term Care 151 10 161

Accreditation Canada Priorities Patient Safety Strengths: Clinical Safety Coordinators Quality Indicator Audits Significant amount of education/training on patient safety Challenges: Span of control of managers/coordinators Recruitment and retention in vacancies # of unmet ROP(s): 0

Accreditation Canada Priorities Client-and Family-Centred Care Strengths: Organization has recognized this is important Patient and Resident Engagement Framework Policy & Procedures Challenges: Implementing Embedding Evaluating

Accreditation Canada Priorities Ethics Strengths: Robust framework Ethics committees throughout the organization at the local level Access to expertise when required Challenges: Continuing to maintain and increase awareness

Accreditation Canada Priorities Risk Management Strengths: Developing a culture of prevention Significant auditing Incident reporting well done in some sites Challenges: Ensuring roles and responsibilities; span of control Reporting of Near misses

Accreditation Canada Priorities Quality Improvement Strengths: Participating in research activities Working to address quality issues raised by residents and families (e.g. related to food; activities) Monthly reporting of corporate quality indicators Challenges: More staff engagement in quality improvement activities Continue monitoring and reporting progress Evaluate improvement to food and activities (especially in smaller and remote sites)

Next Steps Accreditation report Accreditation decision Submission of supplementary evidence

Please note: This presentation is intended to present preliminary findings only. Accreditation Canada reserves the right to alter or revise any of this material based on our further review. Accreditation Canada recommends that the information contained within this “debriefing” be reserved for internal use only.

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