Donald Berman Maimonides Geriatric Centre
On-site survey dates: September 30, 2012 - October 4, 2012
Accredited by ISQua
Montréal, QC
Confidentiality
This report is confidential and is provided by Accreditation Canada to the organization only. Accreditation Canada does not release the report to any other parties.
In the interests of transparency and accountability, Accreditation Canada encourages the organization to disseminate its Accreditation Report to staff, board members, clients, the community, and other stakeholders.
About the Accreditation Report
Donald Berman Maimonides Geriatric Centre (referred to in this report as “the organization”) is participating in Accreditation Canada's Qmentum accreditation program. As part of this ongoing process of quality improvement, an on-site survey was conducted in September 2012. Information from the on-site survey as well as other data obtained from the organization were used to produce this Accreditation Report.
Accreditation results are based on information provided by the organization. Accreditation Canada relies on the accuracy of this information to plan and conduct the on-site survey and produce the Accreditation Report. Any alteration of this Accreditation Report compromises the integrity of the accreditation process and is strictly prohibited.
© Accreditation Canada, 2012
Accreditation Canada is a not-for-profit, independent organization that provides health services organizations with a rigorous and comprehensive accreditation process. We foster ongoing quality improvement based on evidence-based standards and external peer review. Accredited by the International Society for Quality in Health Care, Accreditation Canada has helped organizations strive for excellence for more than 50 years.
On behalf of Accreditation Canada's Board and staff, I extend my sincerest congratulations to your board, your leadership team, and everyone at Donald Berman Maimonides Geriatric Centre on your participation in the Qmentum accreditation program. Qmentum is designed to integrate with your quality improvement program. By using it to support and enable 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 instrument data that your organization has submitted. Please use the information in this report and in your 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 integrating accreditation into your improvement program. We welcome your feedback about how we can continue to strengthen the program to ensure it remains relevant to you and your services.
We look forward to our continued partnership. Sincerely,
Wendy Nicklin
President and Chief Executive Officer
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 3
1.4 Overview by Standards 4
1.5 Overview by Required Organizational Practices 5
1.6 Summary of Surveyor Team Observations 9
2.0 Detailed On-site Survey Results 12
2.1 Priority Process Results for System-wide Standards 13
2.1.1 Priority Process: Planning and Service Design 13
2.1.2 Priority Process: Governance 14
2.1.3 Priority Process: Resource Management 15
2.1.4 Priority Process: Human Capital 17
2.1.5 Priority Process: Integrated Quality Management 19
2.1.6 Priority Process: Principle-based Care and Decision Making 20
2.1.7 Priority Process: Communication 21
2.1.8 Priority Process: Physical Environment 22
2.1.9 Priority Process: Emergency Preparedness 24
2.1.10 Priority Process: Patient Flow 25
2.1.11 Priority Process: Medical Devices and Equipment 26
2.2 Service Excellence Standards Results 27
2.2.1 Standards Set: Infection Prevention and Control 27
2.2.2 Standards Set: Long-Term Care Services 29
2.2.3 Standards Set: Managing Medications 33
2.2.4 Standards Set: Rehabilitation Services 35
3.0 Instrument Results 38
3.1 Governance Functioning Tool 38
3.2 Patient Safety Culture Tool 42
3.3 Worklife Pulse Tool 44
Appendix A Qmentum 46
Appendix B Priority Processes 47
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Table of Contents
Accreditation Canada is an independent, not-for-profit organization that sets standards for quality and safety in health care and accredits health organizations in Canada and around the world. Organizations that are accredited by Accreditation Canada undergo a rigorous evaluation process. Following a comprehensive self-assessment, trained surveyors from accredited health organizations conduct an on-site survey to evaluate the organization's performance against Accreditation Canada's standards of excellence.
Donald Berman Maimonides Geriatric Centre (referred to in this report as “the organization”) is participating in Accreditation Canada's Qmentum accreditation program. This Accreditation Report shows the results to date and is provided to guide the organization as it continues to incorporate the principles of accreditation and quality improvement into its programs, policies, and practices.
Donald Berman Maimonides Geriatric Centre is commended on its commitment to using accreditation to improve the quality and safety of the services it offers to its clients and its community.
1.1 Accreditation Decision
Donald Berman Maimonides Geriatric Centre has earned the following accreditation decision.
Accredited with Exemplary Standing
Executive Summary
1
1.2 About the On-site Survey
• On-site survey dates: September 30, 2012 to October 4, 2012
• Location
The following location was assessed during the on-site survey. 1 Donald Berman Maimonides Geriatric Centre
• Standards
The following sets of standards were used to assess the organization's programs and services during the on-site survey. System-Wide Standards Governance 1 Leadership 2
Service Excellence Standards Managing Medications 3
Infection Prevention and Control 4
Long-Term Care Services 5
Rehabilitation Services 6
• Instruments
The organization administer: Governance Functioning Tool 1
Patient Safety Culture Tool 2
Worklife Pulse Tool 3
Executive Summary
2
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 lists the quality dimensions and shows how many of the criteria related to each dimension were rated as met, unmet, or not applicable during the on-site survey.
Quality Dimension Met Unmet N/A Total
Population Focus (Working with communities to
anticipate and meet needs) 33 0 0 33
Accessibility (Providing timely and equitable
services) 27 0 1 28
Safety (Keeping people safe)
158 2 22 182
Worklife (Supporting wellness in the work
environment) 66 1 1 68
Client-centred Services (Putting clients and
families first) 46 0 0 46
Continuity of Services (Experiencing coordinated
and seamless services) 15 0 0 15
Effectiveness (Doing the right thing to achieve the
best possible results) 238 3 7 248
Efficiency (Making the best use of resources)
31 0 0 31
Total 614 6 31 651
Executive Summary
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1.4 Overview by Standards
The Qmentum standards identify policies and practices that contribute to high quality, safe, and effectively managed care. Each standard has associated criteria that contribute to achieving the standard as a whole. System-wide standards address quality and safety at the organizational level in areas such as governance and leadership, while population-specific and service excellence standards address specific populations, sectors, and services. The sets of 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 number and 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 decimal and not rounded.
Standards Set
Met Unmet N/A
High Priority Criteria
# (%) # (%) #
Met Unmet N/A
Other Criteria
# (%) # (%) #
Met Unmet N/A
Total Criteria (High Priority + Other)
# (%) # (%) # Governance 40 (93.0%) 3 (7.0%) 0 35 (100.0%) 0 (0.0%) 0 75 (96.2%) 3 (3.8%) 0 Leadership 42 (100.0%) 0 (0.0%) 0 86 (98.9%) 1 (1.1%) 0 128 (99.2%) 1 (0.8%) 0 Infection Prevention and Control 31 (96.9%) 1 (3.1%) 9 35 (100.0%) 0 (0.0%) 7 66 (98.5%) 1 (1.5%) 16 Long-Term Care Services 23 (100.0%) 0 (0.0%) 0 72 (100.0%) 0 (0.0%) 1 95 (100.0%) 0 (0.0%) 1 Managing Medications 67 (100.0%) 0 (0.0%) 9 52 (100.0%) 0 (0.0%) 0 119 (100.0%) 0 (0.0%) 9 Rehabilitation Services 25 (100.0%) 0 (0.0%) 1 66 (98.5%) 1 (1.5%) 2 91 (98.9%) 1 (1.1%) 3 228 (98.3%) 4 (1.7%) 19 346 (99.4%) 2 (0.6%) 10 574 (99.0%) 6 (1.0%) 29 Total
Executive Summary
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Accreditation Report
1.5 Overview by Required Organizational Practices
In Qmentum, a Required Organizational Practice (ROP) is defined as an essential practice that an organization must have in place to enhance client safety and minimize risk. Each ROP has associated tests for compliance, categorized as major and minor. All tests for compliance must be met for the ROP as a whole to be rated as met. This table shows how the applicable ROPs were rated during the on-site survey.
Required Organizational Practice Overall rating Test of Compliance Rating Major Met Minor Met
Patient Safety Goal Area: Safety Culture Adverse Events Disclosure
(Leadership)
Met 3 of 3 0 of 0
Adverse Events Reporting (Leadership)
Met 1 of 1 1 of 1
Client Safety As A Strategic Priority (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
(Long-Term Care Services)
Met 2 of 2 0 of 0
Client And Family Role In Safety (Rehabilitation Services) Met 2 of 2 0 of 0 Dangerous Abbreviations (Managing Medications) Met 4 of 4 3 of 3 Information Transfer (Long-Term Care Services)
Met 2 of 2 0 of 0 Information Transfer (Rehabilitation Services) Met 2 of 2 0 of 0
Executive Summary
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Accreditation Report
Required Organizational Practice Overall rating Test of Compliance Rating Major Met Minor Met
Patient Safety Goal Area: Communication Medication Reconciliation As An
Organizational Priority (Leadership)
Met 12 of 12 0 of 0
Medication Reconciliation At Admission (Long-Term Care Services)
Met 4 of 4 1 of 1
Medication Reconciliation At Admission (Rehabilitation Services)
Met 4 of 4 1 of 1
Medication Reconciliation at Transfer or Discharge
(Long-Term Care Services)
Met 4 of 4 1 of 1
Medication Reconciliation at Transfer or Discharge
(Rehabilitation Services)
Met 4 of 4 1 of 1
Two Client Identifiers (Long-Term Care Services)
Met 1 of 1 0 of 0
Two Client Identifiers (Managing Medications)
Met 1 of 1 0 of 0
Two Client Identifiers (Rehabilitation Services)
Met 1 of 1 0 of 0
Verification Processes For High-Risk Activities
(Long-Term Care Services)
Met 2 of 2 1 of 1
Verification Processes For High-Risk Activities
(Rehabilitation Services)
Met 2 of 2 1 of 1
Patient Safety Goal Area: Medication Use Concentrated Electrolytes (Managing Medications) Met 1 of 1 0 of 0 Heparin Safety (Managing Medications) Met 4 of 4 0 of 0
Executive Summary
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Accreditation Report
Required Organizational Practice Overall rating Test of Compliance Rating Major Met Minor Met
Patient Safety Goal Area: Medication Use Infusion Pumps Training
(Long-Term Care Services)
Met 1 of 1 0 of 0
Infusion Pumps Training (Managing Medications) Met 1 of 1 0 of 0 Medication Concentrations (Managing Medications) Met 1 of 1 0 of 0 Narcotics Safety (Managing Medications) Met 3 of 3 0 of 0
Patient Safety Goal Area: Worklife/Workforce Client Safety Plan
(Leadership)
Met 0 of 0 2 of 2
Client Safety: Education And Training (Leadership)
Met 1 of 1 0 of 0
Client Safety: Roles And Responsibilities (Leadership)
Met 1 of 1 2 of 2
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 Audit
(Infection Prevention and Control)
Met 1 of 1 2 of 2
Hand Hygiene Education And Training (Infection Prevention and Control)
Met 2 of 2 0 of 0
Infection Control Guidelines (Infection Prevention and Control)
Met 1 of 1 0 of 0
Infection Rates
(Infection Prevention and Control)
Met 1 of 1 3 of 3
Executive Summary
7
Required Organizational Practice Overall rating Test of Compliance Rating Major Met Minor Met
Patient Safety Goal Area: Infection Control Influenza Vaccine
(Infection Prevention and Control)
Met 3 of 3 0 of 0
Pneumococcal Vaccine (Long-Term Care Services)
Met 2 of 2 0 of 0
Patient Safety Goal Area: Falls Prevention Falls Prevention Strategy
(Long-Term Care Services)
Met 3 of 3 2 of 2
Falls Prevention Strategy (Rehabilitation Services)
Met 3 of 3 2 of 2
Patient Safety Goal Area: Risk Assessment Pressure Ulcer Prevention
(Long-Term Care Services)
Met 3 of 3 2 of 2
Executive Summary
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During the on-site survey, 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 Donald Berman Maimonides Geriatric Centre (DBMGC) can celebrate many successes. As it embarks on a second century of caring for the Jewish elderly of Montreal, it is renewing its strategic plan that will set its direction for the next five years and ensure the Centre provides the best care and quality of life across its many programs. This McGill University teaching center hosts the Helen and Sam Steinberg Day Hospital, and runs several accredited homes, intermediate residences and a long-term care center.
The senior management team of the Donald Berman Maimonides Geriatric Centre also serves as the management team of Jewish Eldercare, and the partnership has led to synergies and efficiencies. The organizations learn from one another and share best practices across the sites. By working together, the organizations have been able to standardize and enhance the level of care for the residents they serve.
The organization is respected as a leader in geriatrics care, due to the vision of its Executive Director and senior leadership team.
With strong community support, the Maimonides Foundation has invested in the Centre’s research and teaching capabilities to advance clinical excellence in geriatric care and to develop leaders from within, and attract new research to Maimonides.
Through an innovative partnership with the Maimonides, Pearson Adult and Career Centre (PACC) created the Maimonides- PACC Learning Institute which offers on-site education programs for patients attendants (PABs ) and Licensed Practical Nurses. Located on the second floor is the spacious state-of –the-art classroom with adjacent learning laboratory. The program provides students who share the Maimonides’ passion for geriatrics the
potential to work here after their education programs.
Recently, the DBMGC introduced an on-site evening program for individuals who wish to become Licensed Practical Nurses. Staff from the Centre may apply for financial support from the Foundation to complete this program.
The Donald Berman Maimonides Geriatric Centre is committed to communicating with residents, clients, families, staff, physicians, volunteers and community partners. Many new methods have been established over the past few years to enhance open communication at all levels. There is a cascade of information from the Board of Directors meetings, to the senior and management team meetings, and notes from both of these are provided to staff to improve awareness of issues facing the organization. The Communications and Foundation teams produce newsletters including Volunteer Viewpoint, Perspectives (distributed internally and through The Montreal Gazette) and The Buzz (Auxiliary), and have launched an intranet site over the past year. The public website has been rebranded, and large-screen information boards provide up-to-date information throughout the Centre. The new branding was introduced to coincide with the renaming of “Maimonides” to the Donald Berman Maimonides Geriatric Centre, in recognition of the transformational gift from the Donald Berman Foundation.
As the new Board reaches the first anniversary of its new mandate, it is encouraged to carry out its planned self-evaluation as a responsibility of the Governance Committee.
The organization is commended for strengthening its capacity in quality management. To demonstrate its commitment to "closing the loop” on risks and quality issues, the quality and risk team should ensure that corrective action is documented.
The strength of the commitment of the Jewish community to the Donald Berman Maimonides Geriatric Centre is one of its greatest assets. There are many examples of families continuing a tradition of financially contributing and volunteering for many generations. With this support, Donald Berman Maimonides Geriatric Centre has every potential of fulfilling its goal of “going further in geriatric care”.
A dedicated physician group coordinates the ongoing medical care for long-term care residents. A partnership with specialists at the Jewish General Hospital provide satellite clinic services to clients who also provide regular visits to clients at the Centre.
The Donald Berman Maimonides Geriatric Centre participates actively in many local, provincial, national and international associations including the local health care network, Order of Nurses of Quebec, Association of Jewish Aging Services and Planetree International.
The Centre has embraced the Planetree philosophy which was introduced in 2008. It helps to drive many of the improvements within the organization. The Centre and the Foundation have made a significant to Planetree and it is visible across the organization. The Centre boasts a Planetree Spa, beautiful lounge space and dining rooms and visiting areas throughout the organization. The Art of Healing program showcases artwork, and there are pianos, plants, pets, and sensory stimulation (the smell of bread baking, aromatherapy and garden areas). Most importantly, staff members are proud of their role in improving the quality of life thought this
interdisciplinary approach.
The clinical ethics committee has developed and implemented an ethical framework. To strengthen the
organization's capacity, further deployment of the framework will promote use of the decision making guide for both clinical and non-clinical ethics issues.
Residents and families expressed an appreciation for the clean, well-maintained buildings and grounds. The dedication of the housekeeping staff helps to maintain a clean environment and their special attention to 'high touch' surface contributes to the infection prevention and control efforts of The Donald Berman Maimonides Geriatric Centre.
The Board of Directors brings their talents, strengths and subject matter expertise to the governance of the Centre, and provides counsel to the Executive Director and her team, and help shape the strategies and policy direction for its future.
The organization continues to promote an awareness of “Safety at Maimonides” and its communication efforts promote the role that everyone plays in making the organization safer for residents, staff, families and volunteers.
There is a strong health and safety program and the Centre enjoys one of the lowest CSST rates in the province of Quebec. There is good recognition of the interface between resident and worker safety.
Community partners express a high level of confidence and satisfaction in their relationships with the organization as a result of trust, mutual respect, and good communications and shared visioning for system improvements. Community partners report that, the Donald Berman Maimonides Geriatric Centre is an excellent partner. They add, “ we can always count on them. "
Accreditation 2009 identified opportunities to complete the Board evaluation process and conduct exit interviews for staff that leave The Donald Berman Maimonides Geriatric Centre.
The organization is encouraged to continue to conduct regular performance reviews and to complete exit interviews to assist with recruitment and retention efforts. Assessing performance and aligning education investments to the personal development needs of staff members will align organization-wide performance improvement with strategic plan.
Executive Summary
9
As the new Board reaches the first anniversary of its new mandate, it is encouraged to carry out its planned self-evaluation as a responsibility of the Governance Committee.
The organization is commended for strengthening its capacity in quality management. To demonstrate its commitment to "closing the loop” on risks and quality issues, the quality and risk team should ensure that corrective action is documented.
The strength of the commitment of the Jewish community to the Donald Berman Maimonides Geriatric Centre is one of its greatest assets. There are many examples of families continuing a tradition of financially contributing and volunteering for many generations. With this support, Donald Berman Maimonides Geriatric Centre has every potential of fulfilling its goal of “going further in geriatric care”.
A dedicated physician group coordinates the ongoing medical care for long-term care residents. A partnership with specialists at the Jewish General Hospital provide satellite clinic services to clients who also provide regular visits to clients at the Centre.
The Donald Berman Maimonides Geriatric Centre participates actively in many local, provincial, national and international associations including the local health care network, Order of Nurses of Quebec, Association of Jewish Aging Services and Planetree International.
The Centre has embraced the Planetree philosophy which was introduced in 2008. It helps to drive many of the improvements within the organization. The Centre and the Foundation have made a significant to Planetree and it is visible across the organization. The Centre boasts a Planetree Spa, beautiful lounge space and dining rooms and visiting areas throughout the organization. The Art of Healing program showcases artwork, and there are pianos, plants, pets, and sensory stimulation (the smell of bread baking, aromatherapy and garden areas). Most importantly, staff members are proud of their role in improving the quality of life thought this
interdisciplinary approach.
The clinical ethics committee has developed and implemented an ethical framework. To strengthen the
organization's capacity, further deployment of the framework will promote use of the decision making guide for both clinical and non-clinical ethics issues.
Residents and families expressed an appreciation for the clean, well-maintained buildings and grounds. The dedication of the housekeeping staff helps to maintain a clean environment and their special attention to 'high touch' surface contributes to the infection prevention and control efforts of The Donald Berman Maimonides Geriatric Centre.
The Board of Directors brings their talents, strengths and subject matter expertise to the governance of the Centre, and provides counsel to the Executive Director and her team, and help shape the strategies and policy direction for its future.
The organization continues to promote an awareness of “Safety at Maimonides” and its communication efforts promote the role that everyone plays in making the organization safer for residents, staff, families and volunteers.
There is a strong health and safety program and the Centre enjoys one of the lowest CSST rates in the province of Quebec. There is good recognition of the interface between resident and worker safety.
Community partners express a high level of confidence and satisfaction in their relationships with the organization as a result of trust, mutual respect, and good communications and shared visioning for system improvements. Community partners report that, the Donald Berman Maimonides Geriatric Centre is an excellent partner. They add, “ we can always count on them. "
Accreditation 2009 identified opportunities to complete the Board evaluation process and conduct exit interviews for staff that leave The Donald Berman Maimonides Geriatric Centre.
The organization is encouraged to continue to conduct regular performance reviews and to complete exit interviews to assist with recruitment and retention efforts. Assessing performance and aligning education investments to the personal development needs of staff members will align organization-wide performance improvement with strategic plan.
Executive Summary
10
Community partners express a high level of confidence and satisfaction in their relationships with the organization as a result of trust, mutual respect, and good communications and shared visioning for system improvements. Community partners report that, the Donald Berman Maimonides Geriatric Centre is an excellent partner. They add, “ we can always count on them. "
Accreditation 2009 identified opportunities to complete the Board evaluation process and conduct exit interviews for staff that leave The Donald Berman Maimonides Geriatric Centre.
The organization is encouraged to continue to conduct regular performance reviews and to complete exit interviews to assist with recruitment and retention efforts. Assessing performance and aligning education investments to the personal development needs of staff members will align organization-wide performance improvement with strategic plan.
Executive Summary
11
Detailed On-site Survey Results
Section 2
This section shows detailed on-site results. When reviewing these results, it is important to review the service excellence and the system-wide results together, as they are complementary.
Accreditation Canada defines priority processes as critical areas and systems that have a significant impact on the quality and safety of care and services. Priority processes provide a different perspective from that offered by the standards, organizing the results into themes that cut across departments, services, and teams.
For instance, the patient flow priority process considers criteria from different sets of standards that each address various aspects of patient flow, from preventing infections to providing timely diagnostic or surgical services. This provides a comprehensive picture of how patients move through the organization and how services are delivered to 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, and comment on each priority process.
Priority process comments are shown in this report. The rationale for unmet criteria can be found in the organization'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 of standards, identify high priority criteria (which include ROPs), and list surveyor comments related to each 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
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2.1 Priority Process Results for System-wide Standards
The results in this section are categorized first by priority process and then by standards set.
Some priority processes in this section also apply to the service excellence standards. Where there are unmet criteria that also relate to services, those results should be shared with the relevant team.
2.1.1 Priority Process: Planning and Service Design
Developing and implementing the infrastructure, programs and service to meet the needs of the community and populations served.
The organization has met all criteria for this priority process.
Surveyor comments on the priority process(es)
The board operates with integrity, commitment and accountability, and recognizes that the organization needs its support in providing the most effective governance. This philosophy guides responsible board decision making. The board reviews its mission, vision and values as part of the planning process and updates them if necessary.
The organization has a well-developed strategic plan, and will soon embark on a new five-year plan, which is founded on a very complete environmental scan. The process for development of the plan included multiple processes for a broad range of community input, from both internal and external stakeholders.
Donald Berman Maimonides Geriatric Centre includes health promotion information in its external
communication (i.e. Perspective, which is distributed to approximately 90,000 homes through The Montreal Gazette). Several educational sessions are offered at the Centre, and a Mini Med School program was introduced as part of the 100th anniversary of the Donald Berman Maimonides Geriatric Centre. A Family Newsletter is distributed to approximately to 700 family members.
The policies and procedures undergo a regular review to ensure that they provide up-to-date guidance to the staff, align with the Planetree philosophy, incorporate best practice information wherever possible and are current with all relevant legislation.
The Donald Berman Maimonides Geriatric Centre was the recipient of the 2010 Laura Gilpin Spirit of Kindness Award, which recognized its extraordinary work in caring for its caregivers. The award was presented during a special ceremony attended by Planetree members from across the globe at its annual convention.
The organization carefully monitors its progress towards achieving its strategic plan. A set of detailed operational goals and objectives are also tracked. Each goal and objective is tracked for completion. The organization has undertaken a review of an innovative partnership to create the Maimonides - PACC Learning Institute (developed with Pearson Adult and Career Centre). The Centre is helping to provide a training site for individuals who want to pursue careers in geriatrics, and support those who wish to continue their education onsite.
Detailed On-site Survey Results
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2.1.2 Priority Process: Governance
Unmet Criteria High Priority
Criteria
Standards Set: Governance
The governing body follows a process to regularly evaluate its performance and effectiveness.
13.4
The governing body regularly evaluates the performance of the board chair based on established criteria.
13.6
The governing body regularly reviews the contribution of individual members and provides feedback to them.
13.7
Surveyor comments on the priority process(es)
The Board of Directors of Donald Berman Maimonides Geriatric Centre has redefined its membership and composition in relation to Bill 127. The new Board is strongly committed to the mission, vision and values of the organization and is finalizing the new Strategic Plan.
The board has engaged with numerous partners including residents of the Centre, family members, union stakeholders, physicians, long-term care and acute care partners, the local health agency, academic partners and members of Jewish community agencies to seek input into its new strategic directions.
To enhance communication with staff, the board introduced a summary report that is shared with staff of the Centre after each meeting. The board encourages feedback from stakeholders and the community about the organization and its services. The board itself has clear guidelines for its members including role
descriptions, expectations, and conflict of interest and ethics guidelines.
A new board orientation program was introduced recently to support new board members in fulfilling their governance mandate. Many board members have personal connections to the Donald Maimonides Geriatric Centre (i.e. that it is home to a grandparent, parent, spouse etc.), and a commitment to ensuring high quality care and services.
A major emphasis of the board's oversight role includes the review of reports on the level of client and staff safety and reviewing the senior management plans to improve services.
The board of directors is aware of the need to evaluate its performance (overall effectiveness, board chair performance and individual member contribution), and has plans to complete this quality improvement process in Spring 2013. In that many of the board members were newly appointed, there was a conscious decision to postpone this until the board was in place for more than one year.
The board has developed an excellent working relationship with the Foundation and both boards work closely to promote the interests of the Centre, and its mission, vision and strategic plan.
Detailed On-site Survey Results
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2.1.3 Priority Process: Resource Management
Monitoring, administration, and integration of activities involved with the appropriate allocation and use of resources.
The organization has met all criteria for this priority process.
Surveyor comments on the priority process(es)
The board and the leadership team work very closely to manage the budget of the Donald Berman
Maimonides Geriatric Centre, and to address the financial pressures which confront the organization in the midst of increasing resident acuity, in an atmosphere of fiscal restraint. By working jointly with Jewish Eldercare, both organizations can seek efficiencies through shared administration, and the sharing of systems and expertise to provide the best overall care for the residents they serve.
The board's finance and audit committee reviews monthly detailed variances with the Director of Finance. The budget variance reports are analyzed carefully with the department managers to assess the causes of any variances, and to seek ways to balance unfavorable variances. A financial report is submitted each month to the Board of Directors for approval.
The local health planning agency has provided support to the organization with funding related to increased acuity or special needs of residents. The Centre is commended for its approach in working closely with clients, families and the medical and clinical teams to try to prevent unnecessary transfers or admissions to acute care. The staff provides many therapies and treatments (e.g. IV therapy, oxygen therapy, specialized feeding) that would not have been possible in long-term care centers in the recent past. The staff has acquired the skills to provide this care in a safe and effective manner, and they are able to support resident choice to receive care in their homes wherever possible.
The Donald Berman Maimonides Geriatric Centre enjoys an excellent relationship with the Foundation. The dynamic team of fundraising professionals is well-known to the staff. The team continues to increase the profile and presence of the Donald Berman Maimonides Geriatric Centre in the community, and is inspiring planned giving, annual giving, and even transformational gifts like the one which led to the renaming of the Centre from the Donald Berman Foundation. The organization is becoming one of the best-loved charities in the Jewish community.
The annual "Battle of the Bands" event is supported by over 250 staff who served as volunteers. This level of commitment to the organization is exceptional. As part of its centennial celebrations the Donald Berman Maimonides Geriatric Centre published "Cooking with Love", and there are golf tournaments and numerous fundraising events throughout the year.
The Foundation has secured the funding to develop a teaching and research center on the site, and there is excitement and anticipation with the potential to advance this vision and continue the organizations strong leadership role in geriatrics.
Procurement is well organized and complies with the supply chain guidelines. Competitive bidding is in place for larger contracts, with openness and transparency regarding procurement decisions. Staff members from various departments participate in the selection of new equipment.
aesthetics and improved the resident safety features.
Detailed On-site Survey Results
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including the “ Suite Dreams “ project which has transformed the resident spaces and modernized the aesthetics and improved the resident safety features.
Detailed On-site Survey Results
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Accreditation Report
The organization has been able to support major renovation projects with the support of its Foundation, aesthetics and improved the resident safety features.
2.1.4 Priority Process: Human Capital
Developing the human resource capacity to deliver safe and high quality services to clients. The organization has met all criteria for this priority process.
Surveyor comments on the priority process(es)
There is an excellent evaluation program established for new employees (for the Registered Nurse, GPL, Licensed Practical Nurse and Nurse's aid/Patients attendants/Orderly). The organization provides 30 days of feedback, and the opportunity for support during the orientation process. New employees are assessed on job knowledge, quality of work, quantity of work, adaptability, initiative, communication, leadership, punctuality, dress code and safety.
The Donald Berman Maimonides Centre's performance reviews are conducted for employees on a three year cycle. It may help to engage employees with the completion of an annual self-appraisal, so that they can identify their own learning needs, which when collated by unit would inform the overall organization-wide needs assessment. For the overwhelming majority of staff, the performance feedback would be positive, and provide an opportunity to recognize their commitments to the Centre.
The organization should continue to conduct exit interviews for staff that leaves the organization, in order to assess its retention and recruitment strategies.
There is an excellent " Safety at Maimonides - What's Your Role? " booklet designed to inform residents, families, volunteers and staff of their role in promoting a safe homelike environment for residents and a safe workplace for staff.
The Donald Berman Maimonides Centre enjoys an excellent record of CSST claims and well-organized Staff Health program. The investment in safety equipment and training is commended. As part of the Planetree environmental, upgrades safety measures have also been directed to ensure a safer workplace (e.g. no slip flooring, safety engineered needles etc.).
The organization has begun using the Grapevine tool to implement 360 degree performance reviews for management staff which includes feedback from staff, peers, and the individual's manager.
There are examples of health and wellness promotion events for staff including on-site massage therapy, a walking program, Zumba classes. With a goal of staff fitness, the centre has beautified their stairwells with bright lighting and added displays of Mandalas (staff-created circular artwork composed on pie-shaped pieces that together form a collage of color).
Future redevelopment plans include a new teaching and research addition. The leadership team has plans to include further Planetree concepts for staff as they design and improve the facilities and lounge space for staff.
The Foundation administers funds aimed at the enhancement of talent and education of the staff. The tuition program is available to assist staff in pursuing their educational and professional development.
Through a unique partnership with Lester B. Pearson, the Donald Berman Maimonides Geriatric Centre plays host to two in-house programs, where PABs/Orderlies and LPNs gain first-hand experience in geriatrics. The Donald Berman Maimonides Geriatric Centre has honored the commitment of those individuals who are graduates of the in-house LPN program by hosting onsite recruitment interviews for competing organizations. This selfless expression of support to students is a heartwarming example of respect.
The work of the Centre and its numerous therapeutic recreation and programs would not be possible without the tremendous support of more than 500 volunteers whose gifts of time and support to the Centre are exceptional. More than 26,000 hours of service are recorded. The Volunteer program recognizes all its volunteers, and awarded one of its canine volunteers with a Planetree Pet Award.
The Breakfast Club program, music therapy, friendly visiting, pet therapy and Dining Program offer a variety of opportunities for younger and older volunteers. The special student MISSIVE program celebrated its 25th anniversary, and there are several examples of youth volunteers who now serve in various capacities throughout the organization as health care professionals, directors on the board or in volunteer administration.
Each year the Centre recognizes its staff and volunteers with long-service awards. There is a tremendous wealth of experience and expertise, and the long-term employment speaks highly of the quality of work life at the Donald Berman Maimonides Geriatric Centre.
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The Donald Berman Maimonides Geriatric Centre has honored the commitment of those individuals who are graduates of the in-house LPN program by hosting onsite recruitment interviews for competing organizations. This selfless expression of support to students is a heartwarming example of respect.
The work of the Centre and its numerous therapeutic recreation and programs would not be possible without the tremendous support of more than 500 volunteers whose gifts of time and support to the Centre are exceptional. More than 26,000 hours of service are recorded. The Volunteer program recognizes all its volunteers, and awarded one of its canine volunteers with a Planetree Pet Award.
The Breakfast Club program, music therapy, friendly visiting, pet therapy and Dining Program offer a variety of opportunities for younger and older volunteers. The special student MISSIVE program celebrated its 25th anniversary, and there are several examples of youth volunteers who now serve in various capacities throughout the organization as health care professionals, directors on the board or in volunteer administration.
Each year the Centre recognizes its staff and volunteers with long-service awards. There is a tremendous wealth of experience and expertise, and the long-term employment speaks highly of the quality of work life at the Donald Berman Maimonides Geriatric Centre.
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2.1.5 Priority Process: Integrated Quality Management
Continuous, proactive and systematic process to understand, manage and communicate quality from a system-wide perspective to achieve goals and objectives.
The organization has met all criteria for this priority process.
Surveyor comments on the priority process(es)
The Donald Berman Maimonides Geriatric Centre has a well-developed risk management program and a quality improvement framework. A new Director of Quality is in place and will assist the organization in the implementation of the quality framework, and fully develop risk, safety and quality indicators.
Quality and safety represent an important focus for the Board of Directors and the leadership team of Maimonides.
The Executive Director is committed to transparency and disclosure of risk and safety events to residents and their families. There is a sincere interest to ensure that concerns and complaints brought to the
Ombudsman, to the Comité de vigilance, or to any of the staff at the Donald Berman Maimonides Centre are resolved effectively and that the organization can continually improve based on all sources of quality feedback.
The team has completed a prospective analysis in the past and is partnering with the Jewish Eldercare Centre to complete a review of the Code Yellow emergency response for missing persons.
The organization celebrates the achievements of staff in quality work whether through the Planetree initiative, the use of best practices, or recognition of educational achievements.
Satisfaction data are utilized to focus the organization’s quality improvements, and the research team has been instrumental in providing qualitative and quantitative analysis to further inform the organizations improvement efforts.
There is strong evidence of the organization’s ability to sustain improvements in quality over time. The introduction of a new food temperature regulation system, a falls prevention program, a restraint reduction program, and workplace safety to impact CSST rates are just some examples.
Near miss data is also being monitored together with the adverse events to assess opportunities to mitigate risks, and prevent recurrence.
The results of interviews and meetings with several staff, residents, board members and family members indicate that there is a commitment to improve the quality of care and services and that they feel that any concerns are addressed by the appropriate individuals or committees (e.g. nurse manager, Ombudsman, Comité de vigilance etc.).
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2.1.6 Priority Process: Principle-based Care and Decision Making
Identifying and decision making regarding ethical dilemmas and problems.
The organization has met all criteria for this priority process.
Surveyor comments on the priority process(es)
A clinical ethics committee is active and is available to all members of the staff. This active multidisciplinary team supports the clinical team in dealing with ethical issues that arise. The team members present their concern and the committee assists the team via a newly developed ethical decision-making framework. The committee reviews the situation with this framework and makes a recommendation to the clinical team to help them deal with the situation that has been presented. These issues have led to changes in practices guidelines and have improved the staff interactions with the clients and their families.
It is suggested that the team deploys this useful tool to all clinical areas of the Centre. The process would be helpful in assisting all team members in dealing with day to day clinical issues.
There exists a newly redefined research department that has quickly integrated into the interdisciplinary team. The department has continued the efforts that had begun to promote and do research that is promoting the quality of life of the long term geriatric resident. Members of the department have quickly (within the last 18 months) furthered the positive presence of the Centre in the provincial network by being affiliated with McGill University and the University of Montreal, by presenting papers at formal conferences and have been accepted for external funding for research.
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2.1.7 Priority Process: Communication
Communication among various layers of the organization, and with external stakeholders. The organization has met all criteria for this priority process.
Surveyor comments on the priority process(es)
The Centre's management team has placed much effort in the area of communication, as they are aware of the difficulty of ensuring that information is transferred to all members of the personnel on 3 shifts 7 days a week. To access the personnel, residents, families and volunteers the following has been put into place: a dynamic intranet, computerized information board, and a renewed branding program. These were in additional to existing newsletters, booklets and posters.
The communication team has worked to standardize the posters, presentations, and publications to ensure the Centre is presented in a professional standardized manner. All posted information is available in both official languages. Following the Centre's Plantree approach the communication department has developed a postcard to be sent to the residents’ families and friends announcing their "moving" to Donald Berman Maimonides Geriatric Centre. This provides the residents with continued communication with their friends and family and at the same time provides the community with positive information of the Centre. The Centre has created a Facebook page to encourage sharing of information and contacts with the families. With the Centre’s focus on safety a booklet was prepared that describes the safety issues that can arise during an admission and the activities that the family, residents or employees could be done to reduce these risks.
The information system has been working hard to migrate to upgraded software and have ensured the required training to support the changes and this through a link with a community partner. The information systems department also is able to provide the users with a support system. The newly implemented pharmacy program has leaded the team to have new challenges that they have met with ease.
A contingency plan is available but is not yet detailed, the team is encouraged to put the complete plan in writing and make this available to all personnel.
All security protocols are in place in relation to the computerized system and the paper files.
The processes are in place to ensure the security of the files during the active aspect of care as well as the points of care post admission. There exist many audits that are supervised by the medical records
department as a service to the clinical services that leads to improved quality of care.
The staff has been taught how to deliver " Bad News Effectively " which assisted the staff in dealing with difficult situations and at the same time ensured the resident and family with properly informed.
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2.1.8 Priority Process: Physical Environment
Providing appropriate and safe structures and facilities to successfully carry out the mission, vision, and goals. The organization has met all criteria for this priority process.
Surveyor comments on the priority process(es)
Donald Berman Maimonides Geriatric Centre is situated on a beautiful multi acre property, with numerous therapeutic gardens and space for residents, families and staff to walk, or sit and visit. The facility was constructed in the 1960s, and it is well-maintained and many of the areas have been part of a major "Suite Dreams" capital redevelopment project.
The Centre is home to the Helen and Sam Steinberg Day Hospital, and range of services and departments. The organization has plans to increase wheelchair accessibility at the side entrance to its site.
The grounds are very well maintained, well lit and have been made safer and more age-friendly. There are large garden areas that can host the large summer barbeque events, and there is meeting and family spaces which accommodate about 1,000 visitors per day.
The building has excellent bilingual signage and way finding. In addition, there are electronic message boards throughout the organization which include safety messages, important news and events.
The organization has embraced almost entirely environmentally friendly cleaning products which they have deployed throughout the building. Recycling of pop cans and plastic bottles could be investigated.
The use of space is designed with resident care and comfort in mind, and with a strong commitment to staff safety. There are lift devices in place throughout the Centre, and the redevelopment plans include further quality of work life improvements and support for the Centre's education and research mission.
The Centre has carefully designed its new areas to incorporate the best of Planetree philosophy. Improve dining and lounge space. A Planetree Spa is available to provide a soothing and comfortable space for residents and staff. Ceiling designs incorporate clouds and sky designs.
There is a specially designed dining room on the second floor which enables focused support for each resident who needs assistance at dining times.
The Building and Maintenance Committee of the board play an active role in providing leadership to the Centre's redevelopment and maintenance projects. The committee is comprised of professionals (experienced contractors, real estate, interior design, architects and engineers). The impact from this interdisciplinary team's contributions provides an excellent support to the Centre, and the designs bring the best ideas to each project.
The Centre works closely with the Art for Healing Foundation (a non-profit organization whose mission is to bring the healing power of art to hospitals and facilities, transform patient areas into inspiring environments that encourage a sense of serenity and hope). There is exceptional artwork throughout the building which provides sensory stimulation for residents, family members and guests to Maimonides.
organization is encouraged to continue its plans to secure approval for the new redevelopment which will provide better support space.
The Konigsberg Family Room is a beautiful space for visitors. Notwithstanding this feedback, hallways were not observed to be congested in a way that may present a barrier for wheelchair dependent patients. Preventive and corrective maintenance systems are in place and are closely monitored by staff. The team is encouraged to include their overall summary report as part of the overall quality reporting framework of the Centre (e.g. aging reports of work and average repair times for patient safety, urgent, routine, and deferred projects).
The emergency generators are tested and load tested regularly.
There are plans to complete a replacement of the kitchen floor with non-slip flooring.
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The space limitations in the support areas results in some congestion and crowding in hallways. The organization is encouraged to continue its plans to secure approval for the new redevelopment which will provide better support space.
The Konigsberg Family Room is a beautiful space for visitors. Notwithstanding this feedback, hallways were not observed to be congested in a way that may present a barrier for wheelchair dependent patients. Preventive and corrective maintenance systems are in place and are closely monitored by staff. The team is encouraged to include their overall summary report as part of the overall quality reporting framework of the Centre (e.g. aging reports of work and average repair times for patient safety, urgent, routine, and deferred projects).
The emergency generators are tested and load tested regularly.
There are plans to complete a replacement of the kitchen floor with non-slip flooring.
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2.1.9 Priority Process: Emergency Preparedness
Dealing with emergencies and other aspects of public safety.
Unmet Criteria High Priority
Criteria
Standards Set: Leadership
The organization's leaders use the results from post-drill analysis and debriefings to review and revise if necessary its all-hazard disaster and emergency response plans and procedures.
14.6
Surveyor comments on the priority process(es)
The Donald Berman Maimonides Geriatric Centre has revised its emergency response procedures all
emergencies based on universal codes. A Fire Brigade program has been developed and emergency exercises using the MISSIVE program student volunteers helps the organization test its abilities related to a fire or a full evacuation.
The organization purchased a wandering client security system that tracks the location of clients who are at risk of wandering. The helps security staff identifies the location of clients who wander and helps to prevent unauthorized and unsafe leaves of absence or elopements.
The organization is encouraged to document the post-drill analysis and ensure that there is follow-up action on any identified opportunities for improvement, or any education required.
The organization has the capacity to switch from natural gas to electric heating. The redundant heating systems provide an emergency back-up for the organization. In addition the organization has capacity to run with back-up generators.
THe Donald Berman Maimonides Geriatric Center has revised its regional pandemic influenza plan in August 2011. There are clearly written policies and procedures for outbreaks and is evidence of good team
communication in the event of any outbreaks with interdisciplinary support from Infection Prevention and Control, Nursing, Housekeeping, Food Services, Therapeutic Recreation, Volunteers and Communications staff. Information is shared with community partners accordingly.
The organization may wish to consider enhancing its "lock out, tag out" procedures as a resident and staff safety initiative, to ensure that equipment that is unsafe is effectively removed from service and tagged for repair.
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2.1.10 Priority Process: Patient Flow
Smooth and timely movement of clients and their families through appropriate service and care settings. The organization has met all criteria for this priority process.
Surveyor comments on the priority process(es)
Residents are placed on a wait list by an external agency, once on the wait list the Centre sends a letter to the resident, a family member and the social worker on the case. There is an invitation for a Centre visit, this visit is open to others in the community.
Once the person is approaching the time of admission a welcome package is sent out with further details. At any time the telephone questions are answered.
The admission process continues on the day of admission when the resident is welcomed into his new home. A welcome gift is given, explanations given by the person in the admitting office and then the person is presented their new room. The process continues with a structured timeline consisting on deadlines for evaluations, introductions by members of the team etc.
The management team works closely with the community partners in an attempt to reduce transfer times and inappropriate referrals.
At discharge the family has the option of having the staff empty the family member’s room and placing their belongings in a locked cart, thus permitting the family to respect their spiritual beliefs.
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2.1.11 Priority Process: Medical Devices and Equipment
Machinery and technologies designed to aid in the diagnosis and treatment of healthcare problems. The organization has met all criteria for this priority process.
Surveyor comments on the priority process(es)
The organization maintains records of testing of the autoclave which is used for the dental clinic at the Donald Berman Maimonides Geriatric Centre.
There are good interdisciplinary processes for procurement, and evaluation of potential equipment, with controlled trials of new equipment prior to purchase. Staff is actively engaged in evaluating the equipment being considered. The organization has invested heavily in ceiling lifts, and safety equipment to promote the safety and wellbeing. Vendor education has been provided to promote safe use of the lifts.
The Donald Berman Maimonides Geriatric Centre maintains a full inventory of its capital equipment and identifies items requiring replacement for capital budget consideration in consultation with managers in all departments. The system incorporates analysis of the repair history for equipment, which helps inform replacement decisions.
A centralized system of equipment replacement and tracking is coordinated by the Technical Services team. There is a multi-year capital plan, with priorities based on their impact on resident and staff safety. The organization has been successful in maintaining a good supply of safety lifts.
The Foundation is also able to support the purchase of equipment requests from time to time.
There is a comprehensive preventive maintenance (PM) program in place for tracking, with weekly, monthly, quarterly and annual checks that are required. Records are kept and available outlining the corrective action.
As part of the trial and evaluation process, the organization discusses equipment purchases with CSR staff, and works closely with infection prevention and control to ensure that the cleaning procedures are clarified at the time the equipment training and deployment begins.
The organization has a comprehensive process for decontamination of equipment and there are wipes attached to medical devices (e.g. blood pressure units, bladder scanners, and any pumps etc.). A tag out system is available but not consistently used across the organization for broken equipment. The electronic tracking system for equipment assists the organization in verifying whether it has any equipment that has been the subject of Health Canada recalls or safety concerns.
The organization does not complete any sterilization or cold sterilization programs onsite. There is a flash autoclave used in the dental program only, and staff members from the clinic are trained and record the results of test samples to confirm that the sterilizer is functioning effectively. The foot care nurses also provide their own sterile sets for resident care, and the packs are sterilized offsite. Otherwise, all of the equipment is single-use and disposable.
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2.2 Service Excellence Standards Results
The results in this section are categorized first by standards set and then by priority process. Priority processes specific to service excellence standards are:
Clinical Leadership
Providing leadership and overall goals and direction to the team of people providing services. Competency
Developing a highly competent interdisciplinary team with the knowledge, skills and abilities to develop, manage, and deliver effective and efficient programs, services, and care.
Episode of Care
Healthcare services provided for a health problem from the first encounter with a health care provider through the completion of the last encounter related to that problem.
Decision Support
Information, research and evidence, data, and technologies that support and facilitate management and clinical decision-making.
Impact on Outcomes
The identification and monitoring of process and outcome measures to evaluate and improve the quality of services to clients and the impact on client outcomes.
Medication Management
Interdisciplinary provision of medication to clients. Infection Prevention and Control
Measures practiced by healthcare personnel in healthcare facilities to decrease transmission and acquisition of infectious agents.
2.2.1 Standards Set: Infection Prevention and Control
Unmet Criteria High Priority
Criteria
Priority Process: Infection Prevention and Control
The organization stores and handles linen, supplies, devices, and equipment in a manner than protects them from contamination.
8.2
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deal with individual isolations, outbreaks, vaccination clinics and all other infection control issues. They have ensured that the infection control manual is up to date and the tools required by the team are available, easy to use and understand. Clinical guidance is given to the staff throughout an outbreak and recommendations for the care on off hours are given and this is supported by the nursing coordinators. The combined efforts of all the team is noted as very positive. There are close links with the Public Health department who guide the nurses during outbreaks.
The nurses are responsible for and complete data collection for nosocomial infections and multi resistant bacteria. These results are presented to the management team and to the Risk Management team and plan to deal with any concerns that need to be dealt with. There exists a multidisciplinary infection control
committee which meets regularly and ensures a smooth functioning program. To assist the nurses they have developed a process whereby they have access to all microbiology reports and prescriptions for antibiotics, this has enabled them to have a very efficient process to follow up on infections.
The nurses are involved in many forms of education: orientation, in services, ongoing education related to vaccination etc. They are well respected by other members of the team who consult them as required. The nurses meet with all members of the health care team, students, volunteers, residents, families and companions to educate them and to provide vaccinations. The rate of flu vaccines given to residents is very high although they encounter difficulty in reaching 50% of the staff. They are encouraged to continue their efforts in this area.
Audits on hand washing are done, but despite their many efforts to educate the staff on the needs of hand washing the results did not demonstrate a transfer of learning. The nurses in collaboration with the nursing management need to develop strategies to increase the percentage of employees who wash their hands, the use of graphics may be helpful to present the results to the staff.
The food services have put into place all the required policies and procedures to ensure a safe environment. The management team needs to address the issue of lack of space for the laundry department; there is a risk of cross contamination between the clean and dirty linen. The plans of renovation should deal with this issue. The housekeeping staff is vigilant in their efforts to maintain a clean environment and have all of the
required procedures in place to do this.
The assistant director of nursing sits on the administrative services committee and provides the needed link with the infection control team and management.
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Accreditation Report
Surveyor comments on the priority process(es) Priority Process: Infection Prevention and Control
The infection control team is well known to the other members of the Centre for their active role in infection control. They are present on the units at the first sign of an infection and guide the team members as they ensured that the infection control manual is up to date and the tools required by the team are available, easy to use and understand. Clinical guidance is given to the staff throughout an outbreak and recommendations for the care on off hours are given and this is supported by the nursing coordinators. The combined efforts of all the team is noted as very positive. There are close links with the Public Health department who guide the nurses during outbreaks.
The nurses are responsible for and complete data collection for nosocomial infections and multi resistant bacteria. These results are presented to the management team and to the Risk Management team and plan to deal with any concerns that need to be dealt with. There exists a multidisciplinary infection control
committee which meets regularly and ensures a smooth functioning program. To assist the nurses they have developed a process whereby they have access to all microbiology reports and prescriptions for antibiotics, this has enabled them to have a very efficient process to follow up on infections.
The nurses are involved in many forms of education: orientation, in services, ongoing education related to vaccination etc. They are well respected by other members of the team who consult them as required. The nurses meet with all members of the health care team, students, volunteers, residents, families and companions to educate them and to provide vaccinations. The rate of flu vaccines given to residents is very high although they encounter difficulty in reaching 50% of the staff. They are encouraged to continue their efforts in this area.
Audits on hand washing are done, but despite their many efforts to educate the staff on the needs of hand washing the results did not demonstrate a transfer of learning. The nurses in collaboration with the nursing management need to develop strategies to increase the percentage of employees who wash their hands, the use of graphics may be helpful to present the results to the staff.
The food services have put into place all the required policies and procedures to ensure a safe environment. The management team needs to address the issue of lack of space for the laundry department; there is a risk of cross contamination between the clean and dirty linen. The plans of renovation should deal with this issue. The housekeeping staff is vigilant in their efforts to maintain a clean environment and have all of the
required procedures in place to do this.
The assistant director of nursing sits on the administrative services committee and provides the needed link with the infection control team and management.
