Accreditation
Hamilton Health Sciences (HHS) and St. Peter's Hospital are committed to quality of care and service. Participation in the accreditation process is a key action by which we measure our clinical and operational performance against established healthcare provider standards. It not only assists us in identifying opportunities to improve patient care and service, but also serves as a means of transparency and accountability to our communities.
Accreditation Canada's accreditation program - developed over 50 years - has a high degree of recognition in the national healthcare community. The Royal College of Physicians and Surgeons of Canada, for example, stipulates that residency programs will operate only in Accreditation Canada accredited facilities. The Accreditation Canada approach has evolved into an ongoing, interactive 36-month Qmentum cycle that aligns well with our philosophy of continuous quality improvement. The 2008 Final Report issued represents the culmination of a highly successful 36 months' work - and the beginning of the next Accreditation Canada improvement cycle.
The 2008 Final Reports issued to HHS and St. Peter's are both very impressive accomplishments. Both organizations had, following their site survey visits, been issued forecast accreditation decisions of "Accreditation with Condition". Accreditation Canada had identified that although HHS had met 97% of the 1598 applicable standard criteria, two of the 25 patient-safety-related standard criteria (Required Organizational Practices or "ROPs") had not been met. These two ROPs were related to medication reconciliation upon admission, transfer and discharge of HHS patients, and to the preventative maintenance of medical equipment and devices. HHS immediately responded to these identified concerns by creating a plan for implementation of medication reconciliation for all HHS patients, and by reviewing all patient safety-related preventative maintenance activities across HHS. Planning for medication reconciliation implementation was complicated by the fact that the process of medication reconciliation involves introduction of new standardized tasks to be completed at key points in the patient care continuum by a very large number of staff and physicians across all HHS sites. Less than 40% of healthcare providers recently surveyed across Canada met this requirement. An additional complicating factor is the timing of the implementation of medication reconciliation at HHS. The organization is beginning a transition from paper to electronic clinical documentation. Coordinating the implementation of two new, complex, organization-wide processes, while also adhering to prescribed Accreditation Canada timelines, added to the challenge. In the case of the preventative maintenance ROP, HHS was able to submit evidence to Accreditation Canada demonstrating that preventative maintenance activities at HHS are effectively integrated with numerous other patient safety processes (including the nationally-recognized Patient Safety Triads, and Patient Safety Leadership Walkabouts) to ensure that equipment and devices function properly and contribute to quality of patient care. The submission of this evidence related to medication reconciliation and preventative maintenance, and other continuous improvement activities, resulted in HHS achieving a success rate of 100% in meeting the patient safety-related criteria (ROPs) and achieving an overall success rate of 98% in meeting the Accreditation Canada standard criteria. St. Peter's Hospital achieved a stunning 99% compliance rate, but was similarly challenged by Accreditation Canada to address two ROPs: medication reconciliation and falls prevention. St. Peter's staff and physicians responded by successfully spreading a medication reconciliation process from a few test areas to all of its areas. An organization-wide, comprehensive falls prevention strategy was also successfully implemented.
These responses to the findings in the preliminary Forecast Reports resulted in both HHS and St. Peter's being awarded "Accredited" final decisions by Accreditation Canada. Recently, a growing number of healthcare organizations have failed to achieve this award - the highest level of recognition granted by Accreditation Canada. To be fully "Accredited", without "Condition" or "Report", all patient safety-related criteria (ROPs) must be met. Given today's increasing pressures and imperatives placed upon healthcare organizations to provide safe and efficient care and services, being recognized as meeting and successfully integrating national quality standards with other ongoing efforts to better serve our communities is a remarkable accomplishment.
Highlighted in the HHS and St. Peter's Final Accreditation Reports are innovative "Leading Practices" identified as exemplary and worthy of note by other healthcare providers:
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The use of the Glitterbug cleaning process for infection prevention and control - Glitterbug is a special product that is applied to high touch surfaces prior to cleaning. After cleaning, the staff uses a UV light to check the consistency and thoroughness of their work.
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Customer Support Services' Supporting Patient Care Training and Development Program - a comprehensive staff-training program that is complemented by a unique educational program offered to area high school students.
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The Patient Liaison role in surgical care - Specialized nurses at Hamilton General Site liaise with the patient's family, the surgeon and the operative team to provide the family with information and support during operations.
The Final Reports also provide results to Accreditation Canada survey instruments completed by the organizations. HHS achieved excellent results for the Governance Survey instrument and for the Patient Safety Culture Survey Instrument. The Patient Safety Culture Survey was completed by 4321 HHS staff (staff from both clinical and non-clinical areas). The HHS overall grade on Patient Safety was 90.7 (on a 100 point scale) where staff rated the culture as excellent, very good and acceptable at an organizational level and 94.5 at a unit level. The results for St. Peter's were also excellent for both surveys.
Among the positive results and feedback contained in the reports are flags and suggestions for yet further improvements that are already being incorporated into planning and action across the newly amalgamated organizations. Highly successful completion of this Accreditation has set the stage for an exciting and productive journey into the next 36-month accreditation cycle.
If you have have questions or comments, please contact:
Heather Pullen
Manager, Public Relations & Communications
Hamilton Health Sciences
(905) 521-2100, ext. 75939
Attachments:
Accreditation Report - Hamilton Health Sciences (February 2009) (PDF)
Accreditation Report - St. Peter's Hospital (February 2009) (PDF)