Debriefing Presentation North Bay Regional Health Centre 25/11/2012 - 30/11/2012
Surveyor Team Régis Vaillancourt Cholly Boland Anita Marie Harris Darlene J. Furlong Heather Garnett Constantine Bubela
Overview of Survey Process # of Priority Processes: 27 # of Sites: 9
Highlights since Last Survey Successes: Merged organization/new building Values focus Addressed most areas of concern from last survey Reorganization/new leadership Volunteer Ambassadors Challenges: Repeat ROP Financial
Overall Observations Strengths: Partnerships Workplace atmosphere Communication – internal and external Innovation My Meds ER infection follow-ups ‘ER Admissions Nurse’ Ambitious plans
Overall Observations Challenges: Ensuring all sites ‘feel connected’ Consistent operational planning and monitoring Regular performance appraisals for all workers
Overview by Quality Dimension Met Unmet N/A Total Population Focus (Working with communities to anticipate and meet needs) 66 10 76 Accessibility (Providing timely and equitable services) 121 1 122 Safety (Keeping people safe) 578 22 11 611 Worklife (Supporting wellness in the work environment) 174 4 178 Client-centred Services (Putting clients and families first) 205 206 Continuity of Services (Experiencing coordinated and seamless services) 74 Effectiveness (Doing the right thing to achieve the best possible results) 864 44 919 Efficiency (Making the best use of resources) 78 82 2160 86 2268
Overview by Standard Section Met Unmet N/A Total Diagnostic Imaging Services 123 4 131 Governance 73 1 78 Leadership 127 10 3 140 Obstetrics Services 145 147 Infection Prevention and Control 102 103 Ambulatory Care Services 116 121 Biomedical Laboratory Services 52 Blood Bank and Transfusion Services 59 Community-Based Mental Health Services and Supports Standards 124 135
Overview by Standard Section Met Unmet N/A Total Critical Care 127 3 1 131 Emergency Department 129 2 132 Laboratory and Blood Services 176 Managing Medications 119 15 135 Medicine Services 102 105 Mental Health Services 101 9 111 Operating Rooms 99 Rehabilitation Services 92 10 103 Reprocessing and Sterilization of Reusable Medical Devices 95 4
Overview by Standard Section Met Unmet N/A Total Substance Abuse and Problem Gambling Services 100 3 1 104 Surgical Care Services 99 5 2160 86 22 2268
Accreditation Canada Priorities Patient Safety Strengths: Dedicated resources Focussed within programs Engagement Challenges: Two identifiers before meds Patient/family role in safety Reporting/evaluation of surgical checklist
Accreditation Canada Priorities Ethics Strengths: Resources to resolve ethical situations Staff awareness of options Plans to raise awareness Challenges: Board awareness and application in all decisions Consistent awareness across in all areas
Accreditation Canada Priorities Risk Management Strengths: REDS incident reporting system Awareness of clinical risks within programs, especially those in Mental Health Plans for enterprise risk management Challenges: No comprehensive enterprise-wide program
Accreditation Canada Priorities Quality Improvement Strengths: Dedicated resources Focus at board and leadership Incident reviews Commitment to ‘More Time to Care ’ Challenges: Monitoring and reporting on metrics and targets in all areas
Next Steps ▪ Accreditation Decision (10 days). ▪ Accreditation report. ▪ Submission of evidence of action taken. ▪ Continuous Quality Improvement. Congratulations !
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 further review and input by Accreditation Canada. Accreditation Canada recommends that the information contained within this “debriefing” be reserved for internal use only.
For further information, please contact Accreditation Canada 1150 Cyrville Road Ottawa, ON Canada K1J 7S9 Tel: 1-800-814-7769 or 613-738-3800 Fax: 1-800-811-7088 or 613-738-3755 Website: www.accreditation.ca Only Accreditation Canada representatives may deliver this presentation. Accreditation Canada does not accept responsibility for others who may present this material.
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