Routinely Asked Questions by Surveyors in Manitoba

Transcription

1 INSIDER the cypress Staff Newsletter Issue 2/3 4/5 Frequent Questions Edith & Edna What s Inside Required Org. Practices Meet Our Surveyors Edition 108 Oct 3/

2 Frequently Asked Questions (FAQs) From October 6-11, 2013, Canada surveyors from across the country will be in Health Region facilities. Below are several frequently asked questions to review so that you can be as prepared as possible for this exciting visit. Please provide our surveyors with a warm welcome! WHEN IS ACCREDITATION? October 6th to 11th, 2013 WHERE DOES ACCREDITATION OCCUR? occurs in all Health Region Facilities Edition 2108 WHY IS THE REGION INVOLVED IN ACCREDITATION? is important because it allows the Region to assess and evaluate its practices against national standards. WHAT IS ACCREDITATION? is one of the most effective ways for the Health Region to regularly and consistently examine and improve the quality of our services. This is done by evaluating our performance against national standards of excellence. works on a 3 year cycle with a key component being the surveyor visit. WHY DO WE NEED TO BE ACCREDITED? Participating in the accreditation process demonstrates the region s commitment to quality health care for staff, patients, clients, and the community. The quality of our services is also important in the recruitment and retention of staff and physicians. WHO ARE THE SURVEYORS THAT WILL BE VISITING? The surveyors are experienced health care professionals from health services across Canada. For more information on the Surveyors look for the surveyor posters displayed in your facility or view pages 8 to 15 of this special edition of the. WHAT SHOULD WE EXPECT? Surveyors will be conducting tracers which will involve interaction with all levels of front line staff. You may be asked process questions or asked to explain a current practice. Please answer honestly based on how you would normally perform a duty/task. WHAT IS A TRACER? A tracer is a process that is designed to follow the path of a patient or an administrative process. It allows the surveyor to gather evidence about the quality and safety of our care and services. It often includes discussions with staff and/or patients/clients/residents and their families.

3 FAQs Continued ARE THE SURVEYORS ASSESSING ME ON HOW WELL I DO MY JOB? It is important to remember that during a tracer, surveyors are not evaluating individual performance. They are observing processes and procedures to assess the compliance of the Health Region with national standards. WHAT IS AN R.O.P.? WHERE DO I FIND INFORMATION ON ROPS? You may hear the surveyors talk about R.O.P.s. An R.O.P. is a Required Organizational Practice which is an essential practice that organizations must have in place to enhance patient/client safety and minimize risk. There are 37 R.O.P.s in which the Health Region must meet both major and minor compliances in order to be accredited. A few examples of R.O.P.s are Two Client Identifiers, Home Risk Assessment, Suicide Prevention, Medication Reconciliation. You can see the complete list of R.O.P.s on page 6 of this edition of the. WHAT DO I DO IF A SURVEYOR APPROACHES ME? Answer their questions. The surveyors need to gather information to complete their assessments. They could approach any staff member from any department to ask questions. Remember that the surveyors have been invited here by the Health Region and should be welcomed into our facilities. 3 Oct 3/13 WHAT CAN I DO TO PREPARE FOR THE VISIT? Refresh yourself with where policy and procedure manuals and important documents are located in your area. Review your fire drill plan; know where your Emergency Preparedness plans and fan out lists are. Be sure that medication carts and medication rooms are locked. We always need to be thinking about confidentiality, and the surveyors will be assessing this. Make sure patient information is not left out in plain view. Review the 37 Required Organizational Practices. WASH YOUR HANDS!!! Hand Hygiene is going to be evaluated by the surveyors. Wear your name tag WHAT TYPE OF QUESTIONS WILL THEY ASK ME? The Surveyors may ask questions about anything on your unit or facility. Examples may include: What do you do to keep patients safe in your area? Tell me what you know about the region s Vision, Mission, and Values? How is consent obtained for each patient? How do you communicate with other members of your team?

4 Edith & Edna Mock Scenario Ensuring the safety of our patients, residents, clients, and our staff is the #1 value of the Health Region. The question, then, is how does link to safety? Required Organizational Practices (ROPs) are one of these links. ROPs are essential practices put in place to enhance patient/client/resident and staff safety and minimize risk. (NOTE: The characters in this story are fictional and are not made to resemble any Health Region patients, but some of the incidents are based on true facts) Edition 4108 So how do ROPs relate to our everyday work? This is the story of Edith and Edna, a fictional family who requires access to healthcare services in the Heath Region. This story is built to help you further your understanding of each of the ROPs and how they relate to our patients healthcare journeys. All of the 37 ROPs of the Health Region (see page 6 of this edition of the for the complete list) can be linked to the story of Edith and Edna. Edith and Edna Peters, identical twin sisters of Michael and Anna Peters, were born on March 21, Over the years they welcomed to their family four brothers: Vincent (1925), Mark (1929), Paul (1933), and Ronald (1936). Edith and Edna were very close sisters; they spent lots of time together helping on the family farm. While Edith and Edna never got married, they helped raise their many nieces and nephews. They loved to garden and were well known for their pickles and carrot cake. As they aged, they still remained living together on the family farm continuing to work in their garden and quilting during the harsh Saskatchewan winter months. They were active in the community near their farm and were always seen helping out at community functions. One day when coming home from a community function, Edith and Edna were involved in a car accident serious enough that hospitalization was required for both of them. While in Emergency after their accident, Edith and Edna were required to have tests and procedures done. Edith had an injury to her leg and suffered whiplash. She is a diabetic and has no allergies but it is noted that she is sensitive to scents. Edna had a mild concussion; she has a severe allergy to morphine and nuts. Their injuries required them to have a short stay in the hospital where they were admitted to an inpatient ward. After a few days, they were released home with the assistance of home care and therapy services. Edith and Edna spent several more years together, celebrating birthdays with families and friends. As they aged, it became harder for them to live alone on the farm. Their health was deteriorating and they were requiring further assistance. To keep them safe the families helped Edith and Edna move into the community long term care facility. Edith and Edna had been so close that they requested a shared room and this is where they continue to live.

5 Edith & Edna 2 Client Identifiers The 2 Client Identifiers ROP states: The team uses at least two client identifiers before administering medications and before providing any service or procedure. In this exercise we need to ask ourselves, how can the sisters safety be ensured utilizing two client identifiers. It must be kept in mind that they are identical twins with the same first initial and last name, same birthdate, and same address. How can this ROP be exercised when: Admitting them to triage/inpatient? Giving ordered medications? Performing lab or diagnostic procedures? Delivering nutrition requirements? Cleaning their room? Providing treatments? Transferring them to another unit or service? Who would be responsible for checking these identifiers before providing any of the above services? (list all occupations/ disciplines) What would be the difference between services provided as an inpatient, a home care client, or long term care resident? As you review this fictional story and how it relates to to the 2 Client Identifiers ROP, consider the following questions: What 2 client identifier checks can be used to ensure the safety of Edith, Edna, and yourself? When do we utilize 2 client identifiers to keep our workplaces safe? How do we educate patients, families, residents, clients and staff about the requirement of 2 client identifers? 2 Client Identifiers Example: Edith and Edna are sharing room #101, which has two beds; Edith is in bed #1 and Edna bed #2. Edith is on a Morphine patch. You have been off for a few days and they decided to switch beds so that they can take turns having the window view. How can you be sure that you are delivering the right meds, the right dietary requirements, and the right treatment or procedure? 5 Oct 3/13 Questions? If you have questions regarding the Edith & Edna story please contact Jill Gates, Coordinator, at

6 The 37 Required Organizational Practices (R.O.P.s) Edition 6108 Dimension R.O.P. Required Organizational Practice Safety Culture 1 Adverse Events disclosure Safety Culture 2 Adverse Events reporting Safety Culture 3 Client Safety as a strategic priority Safety Culture 4 Client Safety quarterly reports Safety Culture 5 Client safety-related prospective analysis Communication 6 Client and family role in safety Communication 7 Dangerous Abbreviations Communication 8 Information transfer Communication 9 Medication reconciliation as an organizational priority Communication 10 Medication reconciliation at admission Communication 11 Medication reconciliation at transfer or discharge Communication 12 Surgical Safety Checklist Communication 13 Two Client identifiers Communication 14 Verification processes for high-risk activities Medication Use 15 Antimicrobial Stewardship Medication Use 16 Concentrated electrolytes Medication Use 17 Heparin Safety Medication Use 18 Infusion Pumps Medication Use 19 Medication concentrations Medication Use 20 Narcotics Safety Worklife/Workforce 21 Client safety plan Worklife/Workforce 22 Client safety: roles & responsibilities Worklife/Workforce 23 Client safety: education & training Worklife/Workforce 24 Preventative Maintenance Program Worklife/Workforce 25 Workplace Violence Prevention Infection Control 26 Hand-hygiene Audit Infection Control 27 Hand-hygiene education & training Infection Control 28 Infection control guidelines Infection Control 29 Infection rates Infection Control 30 Influenza Vaccine Infection Control 31 Pneumococcal Vaccine Infection Control 32 Sterilization Processes Risk Assessment 33 Falls Prevention Strategy Risk Assessment 34 Home Safety Risk Assessment Risk Assessment 35 Pressure ulcer prevention Risk Assessment 36 Suicide Prevention Risk Assessment 37 Venous Thromboembolism (VTE) Prophylaxis Questions? If you have questions regarding any ROPs please contact Jill Gates, Coordinator, at

7 Meet Our Surveyors 7 Oct 3/13

8 During the surveyor visit, Ms. Edwards will be found in the following Edition EI Wood Building - Regional Hospital - Regional Health Office Jeanette Edwards is currently the Regional Director of Primary Health Care and Chronic Disease with the Winnipeg Regional Health Authority. This work is integrated with the Family Medicine and Primary Care program team. The portfolio includes primary care clinics/services, (including midwifery and antenatal home care); support services to seniors, language access services for the region, and the regional Chronic Disease Collaborative. Within the region, it is this program team that is also the lead for the implementation of primary care renewal strategies. Primary Care in the Winnipeg health region is based on primary health care principles and therefore also includes community development based on organizational capacity building, inter-sectoral partnership development, and mechanisms for engaging citizen participation. In addition to her current role, Jeanette is seconded on a part-time basis to Manitoba Health in the capacity of Special Advisor to the Deputy Minister on Primary Care. In this capacity, Jeanette has led the development and implementation of the Physician Integrated Network Initiative in Manitoba where fee-for-service family physicians are actively engaged in developing complex primary care renewal strategies. Jeanette holds a Masters Degree of Healthcare Administration from the University of Minnesota, and a Bachelor of Occupational Therapy from the University of Manitoba. She is a Certified Health Executive with the Canadian College of Health Leaders, holds Advanced Credentials in Health Care Administration from the University of Minnesota, and a Certificate of Gerontology from the University of Manitoba. Jeanette remains active in teaching at the University of Manitoba. Jeanette has surveyed with Canada for many years in diverse areas such as large health systems, a range of community health services and aboriginal health organizations. Jeanette has also served on the Board of Canada.

9 During the surveyor visit, Mr. MacNeil will be found in the following - Herbert and District Integrated Health Facility - Shaunavon Hospital - Regional Hospital Blaise MacNeil is President and Chief Executive Officer of District Health Authority 2, Nova Scotia, a position he has held since He is responsible for the completion of a merger of acute, community, and long term care agencies that form the Authority. 9 Oct 3/13 Prior to this, Blaise was the Chief Executive Officer of South Muskoka Memorial Hospital in Bracebridge, Ontario. He led the hospital through a $26 million redevelopment project, which saw the addition of 50,000 square feet to a new emergency and ambulatory care department. Blaise worked with nine other hospitals to form Network I in compliance with the Health Services Restructuring Commission. Blaise holds a Bachelor of Science and Education from St. Francis Xavier University. In addition, he received a Certified Management Accounting designation from St. Mary's University and a Master of Health Administration from Dalhousie University. Blaise received the Robert Wood Johnson Award for the graduate student most likely to make a significant contribution to the health care system in Blaise is a past board member of the Hospitals of Ontario Pension Plan. He is a member of the Canadian College of Health Leaders (formerly CCHSE), product review committee, and past Chair of the Nova Scotia Labour Relations Committee. He has been appointed to the Board of Trustees of the Nova Scotia Association of Health Organizations and has been a surveyor since 1997.

10 During the surveyor visit, Mr. Guest will be found in the following Edition Ponteix - Regional Hospital - EI Wood Building - Swift Current Care Centre - Cabri - Prairie Pioneers Lodge Tim Guest is Vice President and Chief Nursing Officer at Annapolis Valley Health,a position he has held since Throughout his career, he has held senior executive positions including Vice President Health Services - Rural, and Chief Operating Officer Rural Sites, and Director Acute Care Service at Peace Country Health in Northwestern Alberta. Tim holds a Masters in Business Administration in Executive Management with a Specialization in Leadership from RoyalRoads University, and a Bachelor of Science in Nursing from the University of Alberta. Tim is also a member of the College of Health Leaders. Tim's greatest strength as a surveyor is his experience in integrated health systems in both Alberta and Nova Scotia, and in both urban and rural, and isolated community settings. Tim is currently on council of the College of Registered Nurses of Nova Scotia, and has also been a councilor of the College and Association of Registered Nurses of Alberta.

11 During the surveyor visit, Mrs. Ruston will be found in the following - Maple Creek - Regional Hospital - Regional Health Office - Palliser Regional Care Centre - Herbert and District Integrated Health Facility Lisa Ruston is Director, Quality, Risk & Medical Affairs at the Peterborough Regional Health Centre, a position she has had since Fall A member of the leadership team, Lisa has had an exemplary track record as a director delivering measurable success in utilization and driving quality improvement corporately and within the surgical services portfolio. 11 Oct 3/13 Lisa has been with the Peterborough Regional Health Centre since 2000, and has held a number of administrative positions there, including Director of Pharmacy, Director of Surgical Services, Director of Medicine & Critical Care and Corporate Director, Quality. Prior to this, Lisa was pharmacy supervisor and supervisor of special projects at Sunnybrook Health Sciences Centre, where she was employed for 16 years. Lisa is a pharmacist by training and holds a Bachelor of Science in Pharmacy from the University of Saskatchewan. She obtained her Hospital Pharmacy Residency Certificate at the Ottawa General Hospital through the University of Toronto. She also holds a Master of Business Administration from Schulich School of Business, York University. Lisa obtained her Alternative Dispute Resolution Workshop Certificates Parts 1 and 2 through the faculty of law at the University of Windsor. Her areas of interest are medication systems, surgical programs including inpatient and perioperative services, and utilization management. Her growing experience as a hospital spokesperson in the media, coupled with her broad range of knowledge of institutional practice has given Lisa a unique overview of health services and has enabled her to find innovative and creative solutions to strategic challenges. She has built a solid record of accomplishments and personal development and is an insightful leader who has achieved results through effective communication and relationship development.

12 During the surveyor visit, Dr. Wheelock will be found in the following 12 Edition Leader - Regional Hospital Brian Wheelock MD is the past Chief of Staff of the Saint John Zone of the Horizon Health Network in New Brunswick. He was the Chief of Staff for six and a half years. He has been responsible for quality of medical care delivered throughout the organization, and has functioned as Chair of the Medical Advisory Committee. In addition, Brian has maintained a full clinical practice in Neurosurgery. He is a past Department Head of Neurosurgery and is an Assistant Professor of Neurosurgery with Dalhousie University. Brian graduated from Dalhousie University Medical School in He holds a Bachelor of Science in Biology from Acadia University and has been a fellow of the Royal College of Physicians and Surgeons of Canada, certified in Neurosurgery, since Brian was trained as a Surveyor for the Royal College of Physicians and Surgeons of Canada and has participated in a special survey at a Neurosurgery Teaching Program in Canada. He has also done surveys on two occasions of Neurosurgery clinical departments in Eastern Canada. Brian is a past president of the Canadian Neurosurgical Society and the Canadian Congress of Neurological Sciences. He is past chair of the Professional Development Committee of the Canadian Neurosciences Federation, and was responsible for the development of continuing medical education projects and opportunities for the Clinical Neuroscientists of Canada. He was a member of the Atlantic Node of the Safer Healthcare Now! (SHN), Canadian Patient Safety Institute and maintains his interest in patient safety. Brian is a member of the Board of Directors of the Canadian Patient Safety Institute (CPSI).

13 During the surveyor visit, Ms. O Brien will be found in the following - Ponteix - Regional Hospital - Vanguard - Eastend - Shaunavon - EI Wood Building Kelli O'Brien is Vice President of Long Term Care and Rural Health with Western Health, a position she has occupied since August This position is responsible for the leadership and direction for four rural health centres and three long term care centres within the Western Region. Prior to this, Kelli was Vice-President of Quality Management and Research with Western Health, which was formed in 2005 through the integration of health boards in Newfoundland and Labrador. 13 Oct 3/13 Throughout her career, Kelli has held a number of leadership positions including Acting Vice-President Clinical Operations, Western Health Care Corporation; Clinical Leader of Physiotherapy; and Acting Program Manager of Rehabilitation with Health and Community Services Western. Kelli holds a Bachelor of Science in Physiotherapy from Dalhousie University and a Master of Science in Rehabilitation from Queen's University. Her research on falls in the elderly has been published in the Journals of Gerontology, and Physiotherapy Canada. She has been the recipient of a Research Award from the Newfoundland and Labrador Physiotherapy Association. In 2009, Kelli completed an EXTRA (Executive Training in Research Application) Fellowship with the Canadian Health Services Research Foundation. Her intervention project introduced a new model of enhanced assisted living for individuals with dementia, which resulted in the organization receiving the National Quality of Life Award in June 2009.

14 During the surveyor visit, Ms. Cassan will be found in the following 14 Edition Maple Creek - Regional Hospital - Gull Lake Doris Cassan has been a registered nurse for 37 years and a surveyor with Canada since She is currently the Patient Care Manager for Emergency, Surgical Suite and Central Service Department at Groves Memorial Hospital in Fergus, a busy small hospital in southern Ontario. Doris has held leadership positions in many other programs in community hospitals including Women's & Children's Health, Dialysis, Ambulatory Care and Chronic Care. Doris is a member of the RNAO and Nursing Leadership Network. She has enjoyed teaching nursing at times, and is a strong advocate for ongoing professional education. She has completed her Masters in Nursing as well as the Nursing Leadership Institute (Dorothy Wylie). In 2012, Doris attained the Canadian Patient Safety Officer designation and CSAO certification in medical device reprocessing.

15 During the surveyor visit, Ms. Butler will be found in the following - Leader - Regional Hospital - Gull Lake - Eastend - Shaunavon Janice Butler is the Corporate Director, Quality, Safety, Risk Management and with BC Emergency Health Services (BCEHS) in British Columbia. EHSC comprises the BC Ambulance Service, BC Bedline and BC Trauma Program. Janice joined the organization in 2011 as part of a major change initiative to bring BCEHS into BC s Provincial Health Services Authority (PHSA). 15 Oct 3/13 Prior to working with BCEHS, Janice was the Director of Quality and Patient Safety for the Vancouver Island Health Authority. She has more than ten years senior leadership experience spanning both provincial and health authoritybased roles. She has been a key participant in the development and implementation of the Patient Safety & Learning System in BC and has recently led implementation with the EHSC. Her background includes extensive experience in both (enterprise) risk management as well as quality and patient safety. Provincial highlights for Janice have included health-related risk management representation at the 2010 Olympic and Paralympic Games table as well as coordination and implementation of the first provincial forum on disclosure. Janice has a Masters in Learning and Training (Health) and is keenly interested in and focused on a leader s role in influencing a change in culture. She was one of only 18 participants selected to participate in the BC Provincial Government s first (and only) Pearson Conversations, modelled on the highly successful Gordon Cook conversations in the United Kingdom.