Rapport D'accrétidation de La Régie Des Hôpitaux Du Yukon 2014 Préparé Par Agrément Canada (En Anglais)

Accreditation Report
Yukon Hospital Corporation

On-site survey dates: May 5, 2014 - May 9, 2014
Accredited by ISQua
Whitehorse, YT
Report issued: May 28, 2014
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.
Any alteration of this Accreditation Report compromises the integrity of the accreditation process and is strictly
prohibited.
About the Accreditation Report
Yukon Hospital Corporation (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 May 2014. 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.
QMENTUM PROGRAM
Accreditation Canada, 2014
A Message from Accreditation Canada's President and CEO
On behalf of Accreditation Canada's board and staff, I extend my sincerest congratulations to your board, your
leadership team, and everyone at your organization on your participation in the Qmentum accreditation program.
Qmentum is designed to integrate with your quality improvement program. By using Qmentum 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 the 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
QMENTUM PROGRAM
A Message from Accreditation Canada's President and CEO
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 4
1.4 Overview by Standards 5
1.5 Overview by Required Organizational Practices 7
1.6 Summary of Surveyor Team Observations 13
2.0 Detailed Required Organizational Practices Results 16
3.0 Detailed On-site Survey Results 19
3.1 Priority Process Results for System-wide Standards 20
3.1.1 Priority Process: Planning and Service Design 20
3.1.2 Priority Process: Governance 22
3.1.3 Priority Process: Resource Management 24
3.1.4 Priority Process: Human Capital 25
3.1.5 Priority Process: Integrated Quality Management 26
3.1.6 Priority Process: Principle-based Care and Decision Making 28
3.1.7 Priority Process: Communication 29
3.1.8 Priority Process: Physical Environment 30
3.1.9 Priority Process: Emergency Preparedness 31
3.1.10 Priority Process: Patient Flow 33
3.1.11 Priority Process: Medical Devices and Equipment 34
3.2 Service Excellence Standards Results 37
3.2.1 Standards Set: Ambulatory Systemic Cancer Therapy Services 38
3.2.2 Standards Set: Biomedical Laboratory Services 42
3.2.3 Standards Set: Diagnostic Imaging Services 44
3.2.4 Standards Set: Emergency Department 46
3.2.5 Standards Set: Infection Prevention and Control 49
3.2.6 Standards Set: Medication Management Standards 51
3.2.7 Standards Set: Medicine Services 56
3.2.8 Standards Set: Mental Health Services 58
3.2.9 Standards Set: Obstetrics Services 61
3.2.10 Priority Process: Surgical Procedures 64
QMENTUM PROGRAM
i Table of Contents Accreditation Report
4.0 Instrument Results 67
4.1 Governance Functioning Tool 67
4.2 Patient Safety Culture Tool 71
4.3 Worklife Pulse 73
4.4 Client Experience Tool 75
5.0 Organization's Commentary 76
Appendix A Qmentum 7
Appendix B Priority Processes 7
QMENTUM PROGRAM
ii Table of Contents Accreditation Report
Yukon Hospital Corporation (referred to in this report as the organization) is participating in Accreditation
Canada's Qmentum accreditation program. 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.
As part of the Qmentum accreditation program, the organization has undergone a rigorous evaluation process.
Following a comprehensive self-assessment, external peer surveyors conducted an on-site survey during which
they assessed this organization's leadership, governance, clinical programs and services against Accreditation
Canada requirements for quality and safety. These requirements include national standards of excellence;
required safety practices to reduce potential harm; and questionnaires to assess the work environment, patient
safety culture, governance functioning and client experience. Results from all of these components are included
in this report and were considered in the accreditation decision.
This 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.
The organization 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
Yukon Hospital Corporation's accreditation decision is:
Accredited (Report)
The organization has succeeded in meeting the fundamental requirements of the accreditation program.
QMENTUM PROGRAM
Executive Summary Section 1
Executive Summary 1 Accreditation Report
QMENTUM PROGRAM
1.2 About the On-site Survey
On-site survey dates: May 5, 2014 to May 9, 2014
Locations
The following locations were assessed during the on-site survey. All sites and services offered by the
organization are deemed accredited.
1 Watson Lake Hospital
2 Whitehorse General Hospital
Standards
The following sets of standards were used to assess the organization's programs and services during the
on-site survey.
System-Wide Standards
Leadership 1
Governance 2
Medication Management Standards 3
Service Excellence Standards
Operating Rooms 4
Surgical Care Services 5
Emergency Department 6
Diagnostic Imaging Services 7
Medicine Services 8
Ambulatory Systemic Cancer Therapy Services 9
Obstetrics Services 10
Mental Health Services 11
Biomedical Laboratory Services 12
Infection Prevention and Control 13
Reprocessing and Sterilization of Reusable Medical Devices 14
QMENTUM PROGRAM
Instruments
The organization administer:
Governance Functioning Tool 1
Patient Safety Culture Tool 2
Worklife Pulse Tool 3
Client Experience Tool 4
QMENTUM PROGRAM
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 shows the number of criteria
related to each dimension that were rated as met, unmet, or not applicable.
Quality Dimension Met Unmet N/A Total
Population Focus (Working with communities to
anticipate and meet needs)
45 9 0 54
Accessibility (Providing timely and equitable
services)
70 6 0 76
Safety (Keeping people safe)
429 69 18 516
Worklife (Supporting wellness in the work
environment)
116 15 0 131
Client-centred Services (Putting clients and
families first)
126 10 2 138
Continuity of Services (Experiencing coordinated
and seamless services)
46 0 0 46
Effectiveness (Doing the right thing to achieve the
best possible results)
594 88 26 708
Efficiency (Making the best use of resources)
52 4 1 57
Total 1478 201 47 1726
QMENTUM PROGRAM
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 are used to measure the organization's compliance with
the standard.
System-wide standards address quality and safety at the organizational level in areas such as governance and
leadership. Population-specific and service excellence standards address specific populations, sectors, and
services. The 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
(90.9%)
4
(9.1%)
0 31
(91.2%)
3
(8.8%)
0 71
(91.0%)
7
(9.0%)
0
Leadership 43
(93.5%)
3
(6.5%)
0 76
(89.4%)
9
(10.6%)
0 119
(90.8%)
12
(9.2%)
0
Medication
Management
Standards
58
(79.5%)
15
(20.5%)
5 50
(84.7%)
9
(15.3%)
5 108
(81.8%)
24
(18.2%)
10
Infection Prevention
and Control
45
(90.0%)
5
(10.0%)
3 36
(83.7%)
7
(16.3%)
1 81
(87.1%)
12
(12.9%)
4
Ambulatory Systemic
Cancer Therapy
Services
35
(85.4%)
6
(14.6%)
5 86
(87.8%)
12
(12.2%)
0 121
(87.1%)
18
(12.9%)
5
Biomedical Laboratory
Services
60
(92.3%)
5
(7.7%)
4 85
(88.5%)
11
(11.5%)
2 145
(90.1%)
16
(9.9%)
6
Diagnostic Imaging
Services
61
(93.8%)
4
(6.2%)
2 58
(96.7%)
2
(3.3%)
1 119
(95.2%)
6
(4.8%)
3
Emergency
Department
31
(100.0%)
0
(0.0%)
0 78
(90.7%)
8
(9.3%)
9 109
(93.2%)
8
(6.8%)
9
Medicine Services 23
(88.5%)
3
(11.5%)
1 63
(91.3%)
6
(8.7%)
0 86
(90.5%)
9
(9.5%)
1
QMENTUM PROGRAM
Standards Set
Met Unmet N/A
High Priority Criteria *
# (%) # (%) #
Met Unmet N/A
Other Criteria
# (%) # (%) #
Met Unmet N/A
Total Criteria
(High Priority + Other)
# (%) # (%) #
Mental Health Services 30
(96.8%)
1
(3.2%)
1 81
(92.0%)
7
(8.0%)
0 111
(93.3%)
8
(6.7%)
1
Obstetrics Services 59
(96.7%)
2
(3.3%)
2 70
(93.3%)
5
(6.7%)
0 129
(94.9%)
7
(5.1%)
2
Operating Rooms 62
(91.2%)
6
(8.8%)
1 26
(86.7%)
4
(13.3%)
0 88
(89.8%)
10
(10.2%)
1
Reprocessing and
Sterilization of
Reusable Medical
Devices
31
(83.8%)
6
(16.2%)
3 39
(68.4%)
18
(31.6%)
2 70
(74.5%)
24
(25.5%)
5
Surgical Care Services 25
(83.3%)
5
(16.7%)
0 53
(81.5%)
12
(18.5%)
0 78
(82.1%)
17
(17.9%)
0
603
(90.3%)
65
(9.7%)
27 832
(88.0%)
113
(12.0%)
20 1435
(89.0%)
178
(11.0%)
47 Total
* Does not includes ROP (Required Organizational Practices)
QMENTUM PROGRAM
1.5 Overview by Required Organizational Practices
A Required Organizational Practice (ROP) is 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 the ratings of the applicable ROPs.
Required Organizational Practice Overall rating Test for 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 Quarterly Reports
(Leadership)
Unmet 1 of 1 0 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
(Ambulatory Systemic Cancer Therapy
Services)
Unmet 0 of 2 0 of 0
(Diagnostic Imaging Services)
Met 2 of 2 0 of 0
(Medicine Services)
Unmet 0 of 2 0 of 0
(Mental Health Services)
Met 2 of 2 0 of 0
(Obstetrics Services)
Met 2 of 2 0 of 0
(Surgical Care Services)
Met 2 of 2 0 of 0
QMENTUM PROGRAM
Major Met Minor Met
Dangerous Abbreviations
(Medication Management Standards)
Met 4 of 4 3 of 3
Information Transfer
Services)
Met 2 of 2 0 of 0
(Emergency Department)
Met 2 of 2 0 of 0
(Medicine Services)
Met 2 of 2 0 of 0
Met 2 of 2 0 of 0
Met 2 of 2 0 of 0
Met 2 of 2 0 of 0
Medication reconciliation as a strategic
priority
(Leadership)
Met 4 of 4 2 of 2
Medication reconciliation at care
transitions
Services)
Unmet 1 of 7 0 of 0
transitions
Met 5 of 5 0 of 0
transitions
(Medicine Services)
Met 5 of 5 0 of 0
transitions
Met 5 of 5 0 of 0
QMENTUM PROGRAM
Major Met Minor Met
transitions
Met 5 of 5 0 of 0
transitions
Met 5 of 5 0 of 0
Safe Surgery Checklist
Met 3 of 3 2 of 2
Safe Surgery Checklist
(Operating Rooms)
Met 3 of 3 2 of 2
Two Client Identifiers
Services)
Unmet 0 of 1 0 of 0
(Biomedical Laboratory Services)
Unmet 0 of 1 0 of 0
Met 1 of 1 0 of 0
Met 1 of 1 0 of 0
(Medicine Services)
Met 1 of 1 0 of 0
Met 1 of 1 0 of 0
Met 1 of 1 0 of 0
(Operating Rooms)
Met 1 of 1 0 of 0
Met 1 of 1 0 of 0
QMENTUM PROGRAM
Major Met Minor Met
Patient Safety Goal Area: Medication Use
Antimicrobial Stewardship
Unmet 0 of 4 0 of 1
Concentrated Electrolytes
Unmet 0 of 3 0 of 0
Heparin Safety
Met 4 of 4 0 of 0
High-Alert Medications
Unmet 3 of 5 2 of 3
Infusion Pumps Training
Services)
Met 1 of 1 0 of 0
Met 1 of 1 0 of 0
(Medicine Services)
Unmet 0 of 1 0 of 0
Unmet 0 of 1 0 of 0
Unmet 0 of 1 0 of 0
(Operating Rooms)
Unmet 0 of 1 0 of 0
Unmet 0 of 1 0 of 0
Narcotics Safety
Met 3 of 3 0 of 0
Patient Safety Goal Area: Worklife/Workforce
Client Safety Plan
(Leadership)
Met 2 of 2 2 of 2
Client Safety: Education And Training
(Leadership)
Unmet 0 of 1 0 of 0
QMENTUM PROGRAM
Major Met Minor Met
Preventive Maintenance Program
(Leadership)
Unmet 3 of 3 0 of 1
Workplace Violence Prevention
(Leadership)
Met 5 of 5 3 of 3
Patient Safety Goal Area: Infection Control
Hand-Hygiene Compliance
(Infection Prevention and Control)
Unmet 0 of 1 0 of 2
Hand-Hygiene Education and Training
Met 2 of 2 0 of 0
Infection Rates
Unmet 1 of 1 2 of 3
Reprocessing
Met 1 of 1 1 of 1
Patient Safety Goal Area: Falls Prevention
Falls Prevention Strategy
Services)
Unmet 0 of 3 0 of 2
Unmet 3 of 3 0 of 2
(Medicine Services)
Met 3 of 3 2 of 2
Met 3 of 3 2 of 2
Unmet 3 of 3 0 of 2
Met 3 of 3 2 of 2
QMENTUM PROGRAM
Major Met Minor Met
Patient Safety Goal Area: Risk Assessment
Pressure Ulcer Prevention
(Medicine Services)
Met 3 of 3 2 of 2
Pressure Ulcer Prevention
Unmet 3 of 3 1 of 2
Suicide Prevention
Unmet 4 of 5 0 of 0
Venous Thromboembolism Prophylaxis
(Medicine Services)
Met 3 of 3 2 of 2
Venous Thromboembolism Prophylaxis
Met 3 of 3 2 of 2
QMENTUM PROGRAM
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 organization, Yukon Hospital Corporation (YHC) is commended on preparing for and participating in the
Qmentum survey program. The organization currently operates three hospitals within the Yukon namely:
Whitehorse General Hospital (WGH), Watson Lake Community Hospital (WLCH) and Dawson City Community
Hospital (DCCH). During this 2014 accreditation survey the hospitals in Whitehorse and in Watson Lake were
visited. Services at Dawson City Community Hospital were not all fully operational at the time of the visit.
The past three years has been a time of significant growth and building for the organization. Since the 2011
survey the WLCH and DCCH have been constructed and opened and have joined the YHC corporation. The
planning, design and approval phases for new magnetic resonance imaging (MRI) equipment and installation has
been completed, and the WGH expansion project is in the planning phase. The Thomson Centre, attached to
WGH, has been renovated and opened with twenty-nine continuing care beds. Although the service is operated
by the Department of Health and Social Services via Continuing Care, the YHC supports the facility by providing
maintenance, food and linen services and security in a lease-tenant arrangement.
Also since the previous survey, the 32 unit residence facility that houses students, locums and staff members and
is located on the WGH campus site has been constructed and opened. This building also houses a day care and
leased office space for government offices. Although there are still plans and work underway for an expansion at
the WGH site, it is time for the organization to consolidate its gains and move forward in operational and
programming areas that were suspended while time and effort was directed to these projects. It is also time to
fully integrate the clinical services delivery policies and procedures between the three hospitals to ensure
consistently high-quality care across the corporations hospital system.
The organization has been active in addressing some of the gaps identified in the report recommendations from
the previous 2011 survey of Whitehorse General Hospital (WGH) and the 2012 Primer survey for Watson Lake
Community Hospital (WLCH). A new performance evaluation program (PEP) is being rolled out at the time of this
2014 survey. It aligns with the strategic priorities of the organization with respect to position accountabilities.
An occupational health and safety (OHS) audit was completed and implementation of the action plan is under
way. The information technology (IT) and systems department has undertaken many new projects to support the
organization both for the WGH site and for its community hospitals, including the introduction of wireless
technology at WGH to support the strategic direction for enhancing the patient experience. The department also
supports the electronic system that interfaces with hospital laboratory, diagnostic imaging and other
report-generating departments, with 80% of physician offices in the community now online. There are plans to
implement the physician order functionality in this system.
The organizations facilities continue to be clean and well maintained. The new community hospital in Watson
Lake is spacious and welcoming. The organization is commended for the progress on emergency preparedness.
Noteworthy are the policies and procedures related to the various emergency codes, evolution of the use of the
incident command system (ICS) and most recently, the extensive mass casualty exercises conducted in
Whitehorse and Watson Lake with federal (former) and regional partners. The organization is encouraged to
ensure that lessons learned from these exercises are acted on and incorporated into quality improvement
initiatives. System processes have been introduced to assist with the standardization, handling/ tracking/
approval and evaluation of business case plans. The soon-to-be launched strategic and financial annual planning
calendar will also help clarify expectations and time lines for the executive/ director/manager group. The repair
and preventive maintenance tracking and documentation is now done via the electronic ARCHIBUS system, and
there are clear processes for tracking fixed assets and capital equipment.
The organization is commended for the noted strengths with inter-professional collaboration among the
pharmacists, physicians and nurses. During the on-site survey this was most effectively demonstrated regarding
the excellent commitment and adoption of a collaborative model of medication reconciliation for admission,
transfer and discharge. The organization is also commended for its comprehensive high-alert medication policy
and procedures as this will enable proactive identification and prevention of potential errors. The organization is
encouraged to ensure that the policy is consistently applied in all practice areas such as for chemotherapy, and
sites such as at Watson Lake. There is a noted concern regarding the lack of an intravenous (IV) admixture
service for preparing IV medications. Specifically, this concerns the high-risk/high-alert medications and need to
prepare them in an area that complies with best practice medication safety standards for the preparation of IV
admixtures. The organization is encouraged to give priority to developing an IV admixture service to address safe
preparation of IV admixtures. The use of medication automation as a consideration for tracking and use in the
administration of high-risk medications such as narcotics and controlled drug substances is recommended for
implementation in the pharmacy, as well as in the emergency department and in the operating room.
The organization is commended for its recruitment of clinical pharmacists that have commitment and dedication
toward optimizing safe patient medication management and using a collaborative approach with
inter-professional team members. The re-organization and re-structuring of Yukon Hospital Corporation (YHC) at
the senior executive level to reflect the strategic priorities of the organization is a work in progress. The
organization is adjusting to this new administrative structure as well as to the integration of the two community
hospital facilities. The organization is encouraged to consider the participation of the chief of staff in executive
team meetings to assist with medical and clinical input to planning and decision-making.
The integrated quality management model provides an excellent framework for identifying all aspects of quality,
safety and risk. It is up to the organization to re-affirm or modify its quality and safety plan. From there, the
organization needs to decide how it will make the quality and safety plan operational and what supports and
structures will be needed to successfully implement, monitor and evaluate that plan. The project management
and business case approach is a valuable tool for use in quality and safety initiatives, clarifying key
accountabilities and deliverables. At the same time, an integrated quality plan for the organization must take
into account: day-to-day operational quality and safety activities such as how and what education is delivered;
how change is managed; a process for developing and approving policy and procedures; occupational health and
safety; infection prevention and control and the supports needed for the regular maintenance of quality and
safety programs.
The organization is encouraged to consider how best to bring the patient/client voice to the table. There are a
number of good models used in Canada where patient engagement and partnerships are used to advance the
quality agenda. The proposed work at YHC to implement a new survey tool to measure patient satisfaction and
engagement will contribute well to the organizations quality journey.
The Secure Medical Unit is commended for the work it has done to promote and encourage interdisciplinary
care. The care plans and Kardex format support this client-centred approach to care. Unit staff members have
reached out to community partners and the new multi-agency committee aimed at improving quality for clients
will enhance collaboration and coordination of care between the key health care provider organizations.
The organization needs to further clarify pharmacy and laboratory and diagnostic imaging professional leadership
accountabilities in the community hospitals. Staff members across the organization need to understand the lines
of communication and authority within the new organizational structure as it relates to their work. In health
care organizations there is often a matrix structure required to ensure there is integration and coordinated
activity. Also needed is aligning clinical accountability of program or discipline-specific leadership while
retaining operational accountability with local managers. In some organizations this coordination and
collaboration occurs via a committee structure and in others it occurs in a less formal way with the expectations
of position roles and responsibilities and support of content experts that support integration activities.
Currently, the Board of Trustees, which is the governing body for the organization, is nearing the end of its own
work to review and affirm/develop governing policies and procedures, sub-committee terms of reference and
other items that will guide its work. Board members have access to the Sharepoint internet-based system where
they can find the governance guide, reference library and organizational policies and procedures. The board
clearly understands it is a governing board and the board chair voiced the boards commitment to quality and
safety and the strategic plan.
Community partners acknowledge the importance of the YHC in the community and in the Territory. They
appreciate the beginning efforts to partner with YHC on patient-related and non-patient related initiatives and
would like further opportunities to communicate and work together. It is suggested the YHC or the YHC
Foundation consider developing a volunteer program. There are opportunities to be realized with respect to a
volunteer-run gift shop, patient visitation and socialization. In addition, a junior volunteer program would
familiarize young people with professions and opportunities in health care.
The organization is experiencing some challenges with acute inpatient beds being taken up by patients requiring
an alternate level of care (ALC) placement. There are examples where surgeries have been cancelled due to
unavailability of beds and where patients have stayed overnight in the emergency department waiting for an
inpatient bed. An organizational culture of safety was evidenced in several areas that were visited during the
survey despite the relatively poor results of the Patient Safety Tool where staff rated patient safety as poor. The
client safety plan and staff attention to safety in specific clinical and support areas is good, although there is
evidence that not all staff members had received annual staff training. The organization supports staff
education and offers a variety of mandatory and non-mandatory education programs, certifications and
in-services. There was evidence however, that mandatory education is not being completed despite efforts by
the organization to hold multiple sessions and offer it in a variety of ways. The risk of employees not completing
education deemed mandatory for safe performance of their role and responsibility poses a significant risk to the
organization. It also poses a risk to the professionals license to practice. An electronic learning management
system (LMS) is being implemented for education appropriate to this form of delivery. Thus far, workplace
hazardous management information system (WHMIS) and hand hygiene instruction are delivered using the LMS.
The Patient Services department is also looking at building education in to the regular staff schedule. The
organization is strongly encouraged to look at ways to ensure compliance in this area. Also, the organization is
encouraged to consider orientation and the implementation of a mentoring system for new graduates,
particularly in the nursing area. Past experience by the organization has shown that nurses receiving several
months of orientation and mentoring leads to long-term employees and better retention of staff.
The organization is encouraged to develop a process for policy and procedure development and approval and to
clarify accountabilities in this area. Ideally, the process would have a policy review component, fast track policy
development and approval process when required and guidelines to help staff write policies. The process would
also ensure that there is alignment between the approval authority for polices and the operational responsibility
for implementing policies. Many policies are being reviewed and at this time and there is a mix of updated and
outdated policies on Sharepoint, some with references that are twenty years old.
Organization inertia in the face of rapid change is not unusual and an understanding of change management is
essential for leaders that are spearheading changes. Engagement with physicians and staff members requires
board support and dialogue, along with a clear mandate for quality and safety, perseverance on issues important
to the organization that impact patient and staff safety and attention to concerns that matter to staff and
physicians. Meaningful change at the point where care or support is being delivered occurs when those involved
are part of the change process and own the change.
QMENTUM PROGRAM
The organization is commended for the noted strengths with inter-professional collaboration among the
pharmacists, physicians and nurses. During the on-site survey this was most effectively demonstrated regarding
the excellent commitment and adoption of a collaborative model of medication reconciliation for admission,
transfer and discharge. The organization is also commended for its comprehensive high-alert medication policy
and procedures as this will enable proactive identification and prevention of potential errors. The organization is
encouraged to ensure that the policy is consistently applied in all practice areas such as for chemotherapy, and
sites such as at Watson Lake. There is a noted concern regarding the lack of an intravenous (IV) admixture
service for preparing IV medications. Specifically, this concerns the high-risk/high-alert medications and need to
prepare them in an area that complies with best practice medication safety standards for the preparation of IV
admixtures. The organization is encouraged to give priority to developing an IV admixture service to address safe
preparation of IV admixtures. The use of medication automation as a consideration for tracking and use in the
administration of high-risk medications such as narcotics and controlled drug substances is recommended for
implementation in the pharmacy, as well as in the emergency department and in the operating room.
The organization is commended for its recruitment of clinical pharmacists that have commitment and dedication
toward optimizing safe patient medication management and using a collaborative approach with
inter-professional team members. The re-organization and re-structuring of Yukon Hospital Corporation (YHC) at
the senior executive level to reflect the strategic priorities of the organization is a work in progress. The
organization is adjusting to this new administrative structure as well as to the integration of the two community
hospital facilities. The organization is encouraged to consider the participation of the chief of staff in executive
team meetings to assist with medical and clinical input to planning and decision-making.
The integrated quality management model provides an excellent framework for identifying all aspects of quality,
safety and risk. It is up to the organization to re-affirm or modify its quality and safety plan. From there, the
organization needs to decide how it will make the quality and safety plan operational and what supports and
structures will be needed to successfully implement, monitor and evaluate that plan. The project management
and business case approach is a valuable tool for use in quality and safety initiatives, clarifying key
accountabilities and deliverables. At the same time, an integrated quality plan for the organization must take
into account: day-to-day operational quality and safety activities such as how and what education is delivered;
how change is managed; a process for developing and approving policy and procedures; occupational health and
safety; infection prevention and control and the supports needed for the regular maintenance of quality and
safety programs.
The organization is encouraged to consider how best to bring the patient/client voice to the table. There are a
number of good models used in Canada where patient engagement and partnerships are used to advance the
quality agenda. The proposed work at YHC to implement a new survey tool to measure patient satisfaction and
engagement will contribute well to the organizations quality journey.
The Secure Medical Unit is commended for the work it has done to promote and encourage interdisciplinary
care. The care plans and Kardex format support this client-centred approach to care. Unit staff members have
reached out to community partners and the new multi-agency committee aimed at improving quality for clients
will enhance collaboration and coordination of care between the key health care provider organizations.
The organization needs to further clarify pharmacy and laboratory and diagnostic imaging professional leadership
accountabilities in the community hospitals. Staff members across the organization need to understand the lines
of communication and authority within the new organizational structure as it relates to their work. In health
care organizations there is often a matrix structure required to ensure there is integration and coordinated
activity. Also needed is aligning clinical accountability of program or discipline-specific leadership while
retaining operational accountability with local managers. In some organizations this coordination and
collaboration occurs via a committee structure and in others it occurs in a less formal way with the expectations
of position roles and responsibilities and support of content experts that support integration activities.
QMENTUM PROGRAM
QMENTUM PROGRAM
Detailed Required Organizational Practices Results Section 2
Each ROP is associated with one of the following patient safety goal areas: safety culture, communication,
medication use, worklife/workforce, infection control, or risk assessment.
This table shows each unmet ROP, the associated patient safety goal, and the set of standards where it appears.
Unmet Required Organizational Practice
Standards Set
Patient Safety Goal Area: Safety Culture
Leadership 15.11 Client Safety Quarterly Reports
The organization's leaders provide the governing body with
quarterly reports on client safety, and include
recommendations arising out of adverse incident
investigation and follow-up, and improvements made.
Medicine Services 15.4
Ambulatory Systemic Cancer Therapy
Services 21.5
The team informs and educates clients and families in
writing and verbally about the client and family's role in
promoting safety.
Services 15.5
Biomedical Laboratory Services 19.2
The team uses at least two client identifiers before
providing any service or procedure.
Services 9.15
Medication reconciliation at care transitions
With the involvement of the client, family, or caregiver (as
appropriate), the team generates a Best Possible
Medication History (BPMH) and uses it to reconcile client
medications at ambulatory care visits where the client is at
risk of potential adverse drug events*. Organizational
policy determines which type of ambulatory care visits
require medication reconciliation, and the how often
medication reconciliation is repeated. *Ambulatory care
clients are at risk of potential adverse drug events when
their care is highly dependent on medication management
OR the medications typically used are known to be
associated with potential adverse drug events (based on
available literature and internal data).
Detailed Required Organizational Practices Results 16 Accreditation Report
QMENTUM PROGRAM
Standards Set
Patient Safety Goal Area: Medication Use
Medication Management Standards 12.9 Concentrated Electrolytes
The organization evaluates and limits the availability of
concentrated electrolytes to ensure that formats with the
potential to cause harmful medication incidents are not
stocked in client service areas.
Operating Rooms 2.3
Surgical Care Services 4.4
Medicine Services 4.4
Mental Health Services 4.4
Obstetrics Services 4.5
The team receives ongoing, effective training on all
infusion pumps for staff and service providers.
Medication Management Standards 2.3 Antimicrobial Stewardship
The organization has a program for antimicrobial
stewardship to optimize antimicrobial use. Note:
Beginning in January 2013, this ROP will only apply to
organizations that provide inpatient acute care services.
For organizations that provide inpatient cancer, inpatient
rehab, and complex continuing care services, evaluation of
this ROP will begin in January 2014.
Medication Management Standards 2.5 High-Alert Medications
The organization implements a comprehensive strategy for
the management of high-alert medications.
Leadership 10.8 Client Safety: Education And Training
The organization delivers client safety training and
education at least annually to the organization's leaders,
staff, service providers, and volunteers, including
education targeted to specific client safety focus areas.
Leadership 9.7 Preventive Maintenance Program
The organization's leaders implement an effective
preventive maintenance program for medical devices,
medical equipment, and medical technology.
QMENTUM PROGRAM
Standards Set
Patient Safety Goal Area: Infection Control
Infection Prevention and Control 1.2 Infection Rates
The organization tracks infection rates; analyzes the
information to identify clusters, outbreaks, and trends;
and shares this information throughout the organization.
Infection Prevention and Control 6.5 Hand-Hygiene Compliance
The organization evaluates its compliance with accepted
hand-hygiene practices.
Patient Safety Goal Area: Falls Prevention
Diagnostic Imaging Services 15.6
Obstetrics Services 18.2
Services 21.2
The team implements and evaluates a falls prevention
strategy to minimize client injury from falls.
Patient Safety Goal Area: Risk Assessment
Surgical Care Services 7.9 Pressure Ulcer Prevention
The team assesses each client's risk for developing a
pressure ulcer and implements interventions to prevent
pressure ulcer development.
Mental Health Services 7.5 Suicide Prevention
The team assesses and monitors clients for risk of suicide.
QMENTUM PROGRAM
Detailed On-site Survey Results Section 3
This section provides the detailed results of the on-site survey. When reviewing these results, it is important to
review the service excellence and the system-wide results together, as they are complementary. Results are
presented in two ways: first by priority process and then by standards sets.
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 includes criteria from a number of sets of standards that 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 19 Accreditation Report
QMENTUM PROGRAM
3.1 Priority Process Results for System-wide Standards
The results in this section are presented first by priority process and then by standards set.
Some priority processes in this section also apply to the service excellence standards. Results of unmet criteria
that also relate to services should be shared with the relevant team.
3.1.1 Priority Process: Planning and Service Design
Developing and implementing infrastructure, programs, and services to meet the needs of the populations and
communities served
Unmet Criteria High Priority
Criteria
Standards Set: Leadership
The organization's leaders develop and implement a process to manage
change.
6.5
QMENTUM PROGRAM
when client and staff safety is at risk.
Surveyor comments on the priority process(es)
The organization reviewed its mission, vision and values statements in 2012, and these are communicated via
the website, annual report and the strategic plan. Governance, senior leadership, staff members and a
variety of stakeholders were consulted during the development of the strategic plan for 2013-2017. One
community partner confirmed their organization had received a letter from the chief executive office (CEO)
inviting their participation in providing input to the plan. Although the organization had not received further
feedback on the strategic plan it had been pleased to have received the letter asking for input. The
organization is encouraged to follow up with community partners regarding providing information on the
strategic plan, with emphasis on the four strategic priorities, one of which is the enhancement of community
partnerships.
During the on-site survey community partners indicated the need for an in-patient mental health facility, and
a desire to share information on emergency medical services (EMS) calls for the purpose of developing
education for EMS personnel around the most common calls. Partners also commented on the gap that exists
because there is no volunteer program in place. Discharge planning was identified as an area where more
work could be done, especially in collaboration with the First Nations Health Program. A rapid Home Care
response to the emergency (ER) department was also confirmed as a worthwhile joint initiative that might
assist with the alternate level of care (ALC) problem.
The organization has been very busy in planning and designing new and expanded services. Decisions are
informed by data from numerous sources and reflect the needs that will occur with the future growth in
population and in specific age-groups. Much effort and time has been expended by operational managers. The
use of a project management approach, documented decision-making and the collaboration of all
stakeholders has been instrumental in increasing the effectiveness and efficiency of planning.
The change processes the organization uses should be reviewed to identify where improvements can be
made. Addressing barriers to change will help the organization make some of the necessary changes required
QMENTUM PROGRAM
3.1.2 Priority Process: Governance
Meeting the demands for excellence in governance practice.
Criteria
Standards Set: Governance
Each member of the governing body signs a statement acknowledging his or
her role and responsibilities, including expectations of the position and
legal duties.
2.6
The governing body uses the ethics framework and evidence-informed
criteria to guide decision making.
3.1
The governing body has a succession plan for the CEO. 7.8
The governing body works with the CEO to establish, implement, and
evaluate a communication plan for the organization.
10.3
The communication plan includes strategies to communicate key messages
to staff, stakeholders, and the community.
10.4
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 Yukon Hospital Corporation (YHC) Board of Trustees is committed to patient safety and quality
improvement. Board members have recently undergone an introspective review of their governance guide
which has resulted in an improved, comprehensive set of guidelines to assist trustees in their governance
work. Completion of this guide and implementation of new processes and procedures is expected in the next
few months.
The board trustees recently received training in accessing Sharepoint which is the organization's
internet-based software that allows access to YHC policies and procedures as well as the governance guide
and reference library for the board. The reference library includes the Yukon Hospital Act, service
Agreements, strategic plan, corporate bylaws and medical staff bylaws and rules.
The YHC mission, vision and values have guided the board and senior leadership team in the development of
their strategic plan for 2013-2017. The current operational plan for 2014-2015 clearly outlines the activities
to be undertaken in each of the four strategic priority areas; patient experience, organizational capability,
engaged people and effective partnerships.
risk.
QMENTUM PROGRAM
to monitor and evaluate progress on the organization's efforts to mitigate or eliminate identified areas of high
risk.
The board sets performance expectations and monitors organizational performance. The board is encouraged
QMENTUM PROGRAM
3.1.3 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.
Resource management in the organization is well-organized and supported by well-prepared staff members in
the financial services, materials management and facility services of the organization.
The gated process used in capital expenditures clearly delineates the capital approval process. The process is
supported by business case templates and checklists that remind those submitting requests about the
strategic priorities of the organization and quality, safety and risk impacts of the purchase. The gated process
also includes an evaluation of the expenditure to determine whether or not it met expectations and achieved
the intended results.
The creation of a strategic and financial planning calendar for the organization will help managers, directors
and the senior leadership team in their own operational planning. Use of Sharepoint to host financial
templates and documented process guidelines might be a consideration to expedite internal communication
and decision-making around resource management decisions.
QMENTUM PROGRAM
3.1.4 Priority Process: Human Capital
Developing the human resource capacity to deliver safe, high quality services
Criteria
The organization delivers client safety training and education at least
annually to the organization's leaders, staff, service providers, and
volunteers, including education targeted to specific client safety focus
areas.
10.8
ROP
10.8.1 There is annual client safety training, tailored to staff needs
and the organization's client safety focus areas.
MAJOR
There are numerous ways the organization supports its staff members and shows appreciation. The
occupational health and safety (OHS) program, a day care that is accessible to staff, an on-site gym,
long-service recognition awards, barbecues, and Christmas banquets are all examples of how employees are
supported. Competitive salaries and excellent benefits and a good work environment contribute to the low
turnover rate (8 % per year 2% quarterly).
There is a clinical nurse educator and staff development officer that coordinate and provide continuing
education to staff members along with others in the organization such as the OHS officer and the infection
prevention and control nurse. Despite some of the education being mandatory, staff attendance and
completion of mandatory education is lacking. As previously noted, this is a safety issue and requires action
by the organization to ensure its staff are trained and prepared on all mandatory topics, and that this
information be tracked and maintained. There were a number of comments made during the on-site survey
regarding the need for a longer and better orientation with some type of formal mentoring program
particularly for nursing related positions.
Personnel records are secured in the human resources (HR) department in a room that is locked. It was
observed that although some files held certificates of attendance at specific courses, records of mandatory
and other forms of education were not maintained in the personnel file. Documentation for some education is
on the Meditech system and some is tracked in the new electronic Learning Management System (LMS). It is
suggested the organization consolidate the tracking and documentation of education, particularly mandatory
education in one system. It is suggested the human resources information system would help in tracking and
documenting many aspects of personnel information, including education and immunization status.
Training for succession has proven to be a positive program for the organization and now requires review, and
positions or functional areas for succession targeted.
QMENTUM PROGRAM
3.1.5 Priority Process: Integrated Quality Management
Using a proactive, systematic, and ongoing process to manage and integrate quality and achieve organizational
goals and objectives
Criteria
The organization's leaders support leaders throughout the organization to
develop the knowledge and skills necessary to carry out ongoing quality
improvement.
3.3
The organization's leaders provide opportunities for leaders throughout the
organization to participate in collaborative quality improvement initiatives.
3.4
The organization's leaders are involved in leading quality improvement
initiatives.
3.5
The organization's leaders implement an integrated risk management
approach to mitigate and manage risk.
12.2
The organization's leaders provide the governing body with quarterly
reports on client safety, and include recommendations arising out of
adverse incident investigation and follow-up, and improvements made.
15.11
ROP
15.11.2 The reports outline specific organizational activities and
accomplishments in support of client safety goals and
objectives.
MINOR
15.11.3 There is evidence of the governing body's involvement in
supporting the activities and accomplishments, and acting on
the recommendations in the quarterly reports.
MINOR
The organization's leaders develop and implement an integrated quality
improvement plan.
16.1
The organization's quality management council has not met for the past year while the board was discussing
how the quality management sub-committee would be structured. Safety reports to the board have become
part of the CEO's performance report.
During the on-site survey there was evidence to suggest that the long time it has taken to work on the quality
structure may be contributing to delays in moving the quality agenda forward. This is also affecting: ability to
respond in a timely way to recommendations such as those made following the emergency response exercise
in 2013; progress in the area of updating policies and procedures; taking action on plans made in response to
the Health Insurance Reciprocal of Canada (HIROC) risk assessment and following up on quality improvement
in area such as hand hygiene audits and improvement initiatives. The collection of some quality and safety
data has continued. Nevertheless, work on quality is being done in an environment without a formal
coordinating or collaborating body to expedite the work.
It is not clear how the quality and safety model is being applied at this time. There are quality content
experts in the organization that report to the executive lead on quality and it appears they are using a
project management approach to their work. This makes the dissemination of information and operational
decision-making around quality, particularly for initiatives that impact more than one service area or program
or site challenging. The loss of the collective input and work of quality management committee members
represents a risk to the organization and emphasizes a reactive rather than proactive approach to quality
issues.
The organization's system approach to quality and safety in areas such as finance, human resources and other
non-clinical areas is excellent. The clinical areas would benefit from the process work that has been and is
being done in these support areas.
QMENTUM PROGRAM
It is not clear how the quality and safety model is being applied at this time. There are quality content
experts in the organization that report to the executive lead on quality and it appears they are using a
project management approach to their work. This makes the dissemination of information and operational
decision-making around quality, particularly for initiatives that impact more than one service area or program
or site challenging. The loss of the collective input and work of quality management committee members
represents a risk to the organization and emphasizes a reactive rather than proactive approach to quality
issues.
The organization's system approach to quality and safety in areas such as finance, human resources and other
non-clinical areas is excellent. The clinical areas would benefit from the process work that has been and is
being done in these support areas.
QMENTUM PROGRAM
3.1.6 Priority Process: Principle-based Care and Decision Making
Identifying and decision making regarding ethical dilemmas and problems.
Criteria
The organization's leaders have a process for gathering and reviewing
information about trends in ethics issues, challenges, and situations.
1.8
The organization's leaders use information about trends in ethics issues,
challenges, and situations to improve the quality of services.
1.9
An objective reviewer or body reviews the organization's formal research
projects.
1.11
The organization has an excellent ethics framework, which is well-developed and based on the ethics
principles of beneficence and nonmaleficence, autonomy, fairness and impartiality. There is a procedure in
place highlighting how staff members can access support and how to work through the process. This
framework however, is not clearly understood by front-line staff members. The YHC leadership recognizes
the need to revitalize the framework to increase support for staff members and to embed the framework in
the strategic planning for the organization. There is a need to incorporate a mechanism for documenting the
resolution to ethic issues reviewed, as well as a need to analyze and trend emerging ethics issues. Of note is
that while front-line staff members were not familiar with the framework on ethics they all expressed how
they seek support from their manager should an ethical dilemma arise in their work place.
The organization needs to revise its research ethics policy as it was last reviewed in 2004. In particular there
is a need to ensure that the final approval for research study activity in the YHC is granted by an arms length
committee or board as per National Tri-Council Policy, as opposed to final approval being granted by the
senior management team and/or the medical advisory committee.
QMENTUM PROGRAM
3.1.7 Priority Process: Communication
Communicating effectively at all levels of the organization and with external stakeholders
Criteria
The organization's leaders work with the governing body to develop and
implement a communication plan to disseminate information to and receive
information from internal and external stakeholders.
7.4
The organization's leaders seek input from stakeholders on a regular basis to
evaluate the effectiveness of their relationships with them.
7.5
The recent hiring of a Manager of Communications speaks to the organization's commitment to focus on
enhancing its internal and external communications and promoting engagement of stakeholders. A priority for
the organization is the development of a communication plan.
The board has identified five stakeholder types in its governance guide in the area of stakeholder
relationships. This information will assist in the development of the communication plan and will provide
direction in the area of community and government relations. More work to that which is already ongoing is
required in the area of collaborating with partners and external stakeholders. Community partners
acknowledge there is more collaboration in the past year however, there is an appetite for more
communication and collaboration on issues of mutual interest by partners that provide health services.
The organization's policy and procedures are in transition to a new format. There are policies and procedures
in place which were last reviewed eight years ago and others contain old references. The organization is
encouraged to continue the work on policy review and updating. Sharepoint is a powerful electronic vehicle
for sharing information that is available to the board, physicians and staff. The information technology (IT)
and systems department does an excellent job in implementing and supporting computer technology and
systems of electronic information that has been prioritized by the senior leadership team.
QMENTUM PROGRAM
3.1.8 Priority Process: Physical Environment
Providing appropriate and safe structures and facilities to achieve the organization's mission, vision, and goals
Given that Whitehorse General Hospital's facility was completed in 1997, it no longer meets all current
building codes, requiring 'grandfathering' of select standards. The plan for staged upgrades to the physical
plant in Whitehorse is under active development.
It is understood that Watson Lake and Dawson City sites meet all codes and standards and have full
redundancy in critical operating systems.
QMENTUM PROGRAM
3.1.9 Priority Process: Emergency Preparedness
Planning for and managing emergencies, disasters, or other aspects of public safety
Criteria
Standards Set: Infection Prevention and Control
The policies and procedures for identifying and managing outbreaks and
pandemics are available to staff, service providers, volunteers, clients, and
families.
14.2
The policies and procedures include defined roles, responsibilities, and
accountabilities for staff, service providers, and volunteers who are
involved in identifying and managing outbreaks and pandemics.
14.5
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
The Yukon Hospital Corporation (YHC) has a well-developed emergency preparedness plan with clear policies
and procedures for the various types of codes such as code red for fire, code green for evacuation, and so on.
The manual is current and is comprehensive in addressing all types of emergencies that may present at any of
the three sites that make up the YHC.
The organization has adopted the incident command system (ICS) to put into operation response to any
significant disaster or emergency, and it links to other municipal and government agencies as part of the
regional joint emergency operations centre to ensure a coordinated community response should the need
arise.
During the clinical tracer, and at both sites visited namely, Whitehorse General Hospital (WGH) and Watson
Lake Community Hospital (WLCH), staff members demonstrated their knowledge of the emergency
preparedness plan and were familiar with where to locate the emergency preparedness binder for further
information. Drills have been conducted to familiarize staff members with the planned procedures. Work is
underway to incorporate learning modules on emergency preparedness into the new e-learning system.
Both communities that the surveyor team visited have participated in regional code orange (mass casualty)
drills with their regional and territorial partners. Operation Nanook was an extensive mass casualty exercise
conducted in partnership with the Canadian Armed Forces, which took place in July 2013 in Whitehorse. The
exercise evaluation identified a number of strengths of the organization's emergency preparedness, as well as
areas for improvement. It is recommended that YHC ensure there is a process in place to action
recommendations emerging from the post-drill analysis and debriefing.
Managers at the WGH site have received basic training (ICS Level 100 & 200) in the adopted incident
command system model, which is aligned with the territorial response to managing major incidents. Staff
been brought forward in the lessons learned documentation for the past three (3) drills. The organization is
encouraged to ensure that training is undertaken, consistent with the recommendation and Accreditation
standards 14.6 and 14.7.
QMENTUM PROGRAM
members at the Watson Lake site have not received this training. This recommendation for basic training has
been brought forward in the lessons learned documentation for the past three (3) drills. The organization is
encouraged to ensure that training is undertaken, consistent with the recommendation and Accreditation
standards 14.6 and 14.7.
QMENTUM PROGRAM
3.1.10 Priority Process: Patient Flow
Assessing the smooth and timely movement of clients and families through service settings
Criteria
Standards Set: Surgical Care Services
The team uses a standardized process to prioritize and schedule elective
procedures.
6.7
The organization has implemented several strategies for managing short-term and long-term utilization and
patient flow problems. The morning huddles at 0845 hours and the discharge meetings at 1500 hours are
intended to provide up-to-date information on bed demands and availability. Group problem-solving occurs
and efforts are made to ensure patients are safely and appropriately assigned a bed. Clinical nurse leaders
that cover the hospitals 24/7 not only provide clinical resource support, staff replacement and
re-deployment, they monitor the hospitals for potential discharges. A social worker begins discharge planning
on all patients shortly after admission.
A comment from a community partner was that there could be more collaboration with the First Nations
Health program and the community.
The organization is challenged to look at initiatives that are being successfully used in other jurisdictions such
as the rapid response Home Care assessor role. The assessor attends patients in the emergency department
that may be candidates for discharge if supports can be arranged, rather than admitting someone that does
not require acute care. Also, co-horting alternate level of care (ALC) patients and managing them
appropriately such as dressing these patients for meals, activities, and socializing might also result in a return
to the home rather than a long-term-care (LTC) admission. The organization is encouraged to look at a
volunteer program for the hospitals where socialization and activities could be part of their role.
There is an excellent diagnostic imaging (DI) process for 'flowing' patients with diagnostic lumpectomies via
admitting, DI and to the operating room (OR).
It is recommended the organization re-name the highly visible binder located in the emergency department
which currently has the title: Frequent Flyers. Titles such as individualized care plans or shared community
care plans would be more appropriate.
QMENTUM PROGRAM
3.1.11 Priority Process: Medical Devices and Equipment
Obtaining and maintaining machinery and technologies used to diagnose and treat health problems
Criteria
Standards Set: Diagnostic Imaging Services
The team follows the organization's policies and procedures and
manufacturer's instructions for cleaning and reprocessing diagnostic devices
and equipment.
8.9
Standards Set: Infection Prevention and Control
The organization appropriately contains and transports contaminated items
to the reprocessing unit or area.
12.9
The organization has written requirements for education, qualification, and
competency of staff involved in the reprocessing of endoscopy devices.
13.1
The organization's leaders implement an effective preventive maintenance
program for medical devices, medical equipment, and medical technology.
9.7
ROP
9.7.3 The organization's leaders have a process to evaluate the
effectiveness of the preventive maintenance program.
MINOR
Standards Set: Operating Rooms
The operating room team appropriately contains and transports
contaminated items to the reprocessing unit or area.
12.5
Standards Set: Reprocessing and Sterilization of Reusable Medical Devices
The organization collects information at least annually about service
volumes and patterns of medical device use.
1.1
The organization reviews its operational plan and the information it collects
about service volumes and equipment use to decide which reprocessing and
sterilization services are offered within the organization.
1.2
The team works with others in the organization to limit the use of flash
sterilization to emergencies only, and never for complete sets or
implantable devices.
1.3
The organization conducts baseline and annual competency evaluations of
staff members involved in reprocessing and sterilization.
2.5
The organization documents and retains records of education, training, and
competency assessments.
2.7
QMENTUM PROGRAM
The organization limits access to the medical device reprocessing
department to appropriate team members, and posts clear signage limiting
access to all entry points.
3.2
The organization sets and follows policies that address the management of
the medical device reprocessing department, the team, all aspects of the
sterilization process, safety, infection control, and quality control.
4.1
When establishing or updating the team's infection prevention and control
policies, the team works closely with the organization's IPAC staff, team, or
committee.
4.2
The team follows a process to establish and maintain its Standard Operating
Procedures (SOPs) for reprocessing and sterilization.
4.3
The team writes its SOPs in a clear, concise, and consistent way. 4.4
The team documents and maintains policies, SOPs, standards of practice,
and manufacturers' instructions in a manual.
4.6
All team members have access to the manual. 4.7
The team tracks changes to policies, SOPs, standards of practice, and
manufacturers' instructions using a document control procedure.
4.10
The team leaders approve in writing new and updated SOPs. 4.11
Staff members apply proper hand hygiene technique before beginning and
after completing work activities, as well as at other key points to prevent
infection.
5.5
The team follows a detailed dress code while in the clean reprocessing area
that addresses clothing, hair, jewelry, artificial fingernails of any form, and
covered footwear.
5.7
If prion contamination is suspected, e.g. Creutzfeldt-Jakob disease, the
team follows accepted guidelines from the Public Health Agency of Canada
to handle, quarantine, and incinerate the device, as appropriate.
8.3
The organization limits and monitors access to the storage area to
appropriate team members.
10.2
The team has a documented quality management system for its
reprocessing and sterilization services that integrates principles of quality
assurance, risk management, and continual improvement.
12.1
As part of the quality management system, the team engages in an annual
review of reprocessing and sterilization activities, with formal reports
provided to the organization's senior management.
12.2
QMENTUM PROGRAM
The quality management system documents are accessible to staff and
team members.
12.3
The team monitors compliance with policies and procedures, safe work
practices, and OHS requirements in the reprocessing unit or area.
12.5
The team leaders review the quality management system regularly. 12.8
The team participates in periodic audits. 12.9
The day-to-day management of devices and equipment appears to be managed well. Staff members are
trained and diligent in their efforts. The volume of devices and equipment processed is relatively small and
there may be a risk of losing sight of the critical nature of the work involved. It is suggested that the
organization set as a priority, the formalization of the processes, policies and training records and also, to
clarify and reinforce expectations and permit regular feedback to ensure consistently high-quality work.
QMENTUM PROGRAM
3.2 Service Excellence Standards Results
The results in this section are grouped first by standards set and then by priority process.
Priority processes specific to service excellence standards are:
Episode of Care - Ambulatory Systemic Cancer Therapy
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.
Clinical Leadership
Providing leadership and overall goals and direction to the team of people providing services.
Competency
Developing a skilled, knowledgeable, interdisciplinary team that can manage and deliver effective programs
and services
Episode of Care
Providing clients with coordinated services from their first encounter with a health care provider through
their last contact related to their health issue
Decision Support
Using information, research, data, and technology to support management and clinical decision making
Impact on Outcomes
Identifying and monitoring process and outcome measures to evaluate and improve service quality and client
outcomes
Medication Management
Using interdisciplinary teams to manage the provision of medication to clients
Organ and Tissue Donation
Providing organ donation services for deceased donors and their families, including identifying potential
donors, approaching families, and recovering organs
Infection Prevention and Control
Implementing measures to prevent and reduce the acquisition and transmission of infection among staff,
service providers, clients, and families
Surgical Procedures
Delivering safe surgical care, including preoperative preparation, operating room procedures, postoperative
recovery, and discharge
Diagnostic Services: Imaging
Ensuring the availability of diagnostic imaging services to assist medical professionals in diagnosing and
monitoring health conditions
QMENTUM PROGRAM
Diagnostic Services: Laboratory
Ensuring the availability of laboratory services to assist medical professionals in diagnosing and monitoring
health conditions
3.2.1 Standards Set: Ambulatory Systemic Cancer Therapy Services
Criteria
Priority Process: Episode of Care - Ambulatory Systemic Cancer Therapy
With the involvement of the client, family, or caregiver (as appropriate),
the team generates a Best Possible Medication History (BPMH) and uses it to
reconcile client medications at ambulatory care visits where the client is at
risk of potential adverse drug events*. Organizational policy determines
which type of ambulatory care visits require medication reconciliation, and
the how often medication reconciliation is repeated.
*Ambulatory care clients are at risk of potential adverse drug events when
their care is highly dependent on medication management OR the
medications typically used are known to be associated with potential
adverse drug events (based on available literature and internal data).
9.15
ROP
9.15.2 For ambulatory care visits where medication reconciliation is
required, the organization identifies and documents how
frequently medication reconciliation should occur.
MAJOR
9.15.3 During or prior to the initial ambulatory care visit, the team
generates and documents the Best Possible Medication History
(BPMH), with the involvement of the client, family, caregiver
(as appropriate).
MAJOR
9.15.4 During or prior to subsequent ambulatory care visits, the team
compares the Best Possible Medication History (BPMH) with the
current medication list and identifies and documents any
medication discrepancies. This is done as per the frequency
documented by the organization.
MAJOR
9.15.5 The team works with the client to resolve medication
discrepancies OR communicates medication discrepancies to
the client's most responsible prescriber and documents actions
taken to resolve medication discrepancies.
MAJOR
9.15.6 When medication discrepancies are resolved, the team
updates the current medication list and retains it in the client
record.
MAJOR
9.15.7 The team provides the client and the next care provider (e.g.,
primary care provider, community pharmacist, home care
services) with a complete list of medications the client should
be taking following the end of service.
MAJOR
The team has a process to provide clients with detailed instructions
regarding administration and safe handling of oral systemic cancer
therapies.
13.3
QMENTUM PROGRAM
The team educates the client and family regarding preventing, recognizing,
and managing side effects related to systemic cancer therapy.
13.4
The team conducts independent double checks on infusion pumps prior to
administration.
15.3
The team uses at least two client identifiers before providing any service or
procedure.
15.5
ROP
15.5.1 The team uses at least two client identifiers before providing
any service or procedure.
MAJOR
Priority Process: Clinical Leadership
The team uses the information it collects about clients and the community
to define the scope of its services and to set priorities when multiple
service needs are identified.
1.2
The team's scope of services is aligned with the organization's strategic
direction.
1.3
The team regularly reviews its services and makes changes based on
changing priorities as needed.
1.6
The team has sufficient staff to accommodate clients and meet workload
demands.
2.6
Team members have input on work and job design, including the definition
of roles, responsibilities, and case assignments, where appropriate.
4.4
Team leaders regularly evaluate the effectiveness of staffing and use the
information to make improvements.
4.5
The team has a process for identifying and reducing risks to team members
while delivering ambulatory systemic cancer therapy services.
4.8
Priority Process: Competency
Team members have position profiles that define their roles,
responsibilities, and scope of practice.
3.2
The organization trains and regularly reviews with the team and
appropriate staff, the safe handling of systemic cancer therapy medications
and/or contaminated materials.
5.6
Team leaders regularly evaluate and document each team member's
performance and competency in an objective, interactive, and constructive
way.
5.11
Priority Process: Decision Support
Priority Process: Impact on Outcomes
QMENTUM PROGRAM
The team implements and evaluates a falls prevention strategy to minimize
client injury from falls.
21.2
ROP
21.2.1 The team implements a falls prevention strategy. MAJOR
21.2.2 The strategy identifies the populations at risk for falls. MAJOR
21.2.3 The strategy addresses the specific needs of the populations at
risk for falls.
MAJOR
21.2.4 The team establishes measures to evaluate the falls
prevention strategy on an ongoing basis.
MINOR
21.2.5 The team uses the evaluation information to make
improvements to its falls prevention strategy.
MINOR
The team informs and educates clients and families in writing and verbally
about the client and family's role in promoting safety.
21.5
ROP
21.5.1 The team develops written and verbal information for clients
and families about their role in promoting safety.
MAJOR
21.5.2 The team provides written and verbal information to clients
MAJOR
The team follows the organization's defined quality improvement program. 23.1
Priority Process: Medication Management
The organization has established guidelines for safe handling of systemic
cancer therapy medications.
10.1
The team follows established guidelines for safe handling of systemic
cancer therapy medications.
10.2
The team follows organizational guidelines for spills of systemic cancer
therapy medications.
10.4
The team follows an organizational standard format in ordering, labeling,
and administering systemic cancer therapy medications.
11.6
Priority Process: Episode of Care - Ambulatory Systemic Cancer Therapy
The organization is commended on creation of the navigator role for guiding patient access to services in the
community. The team's focus is collaborative and has a strong patient-centred approach to assuring that
open, transparent and safe patient care services are provided with respect and compassion.
The organization strives to recognize the unique needs of patients requiring cancer therapy, with
consideration of respect and culture diversity. The organization is encouraged to focus dedicated leadership
to developing the new team in the provision of cancer therapy services, and to also developing policies and
procedures to assure the safe use of chemotherapies for both patients and staff.
QMENTUM PROGRAM
The cancer chemotherapy team is committed to providing quality cancer care in a manner that is sensitive to
the unique needs of patients with systemic chemotherapies. The team works collaboratively and with a
shared commitment for providing quality services.
The ambulatory services team works collaboratively to provide accurate and timely patient assessment and
treatment aligned with recognized systemic chemotherapy requirements.
The organization has a team committed to patient safety, and is encouraged to equip and train team
members with the knowledge and tools they need to effectively perform their role.
The organization is in the process of developing safe guidelines for the handling of cancer therapies. Given
the recent chemotherapy spill, the organization is encouraged to give high priority to completing the
associated guidelines in the safe handling of cancer therapy medications. The team works collaboratively
with a shared commitment to continuous quality improvement for assuring safe medication practices with
high risk chemotherapies.
QMENTUM PROGRAM
3.2.2 Standards Set: Biomedical Laboratory Services
Criteria
Priority Process: Diagnostic Services: Laboratory
The organization defines clear lines of accountability for laboratory services
delivered across the organization.
5.1
The team defines each member's responsibilities and required qualifications
in position profiles.
5.2
The team is made up of a sufficient number of qualified team members who
are able to carry out the required volume of laboratory services, day-to-day
operations, and any other responsibilities.
5.4
The laboratory is accessible and safe for clients with limited mobility,
visual, or hearing abilities.
7.3
The team ensures critical equipment such as refrigerators is protected with
an uninterruptible power supply.
9.4
The team has a process to develop clear and concise SOPs that are in line
with applicable regulations and standards of practice for laboratory
services.
11.1
The team has access to SOPs that are applicable to the activities it carries
out.
11.2
The team updates its SOPs every two years or more often if required. 11.3
The team has a process to review and approve revisions to the SOPs. 11.4
The team provides information or training to team members before
implementing a new or revised SOP, if required.
11.5
The team regularly evaluates compliance with its SOPs and makes changes
as needed.
11.6
The team uses at least two client identifiers before providing any service or
procedure.
19.2
ROP
19.2.1 The team uses at least two client identifiers before providing
any service or procedure.
MAJOR
The team has a policy and procedure manual for the LIS and its applications
that is available to team members at all times, and that is regularly
updated to make sure it is complete and accurate.
24.1
The team has a safety officer who develops, maintains, and monitors the
laboratory safety program.
26.1
QMENTUM PROGRAM
The team defines the elements of the quality management system in a
quality policy statement and makes it available in a quality manual.
30.2
The team assigns an individual to establish and oversee the quality
management system.
30.3
The team identifies and monitors quality indicators to evaluate its
performance and shares the results with team members and other
programs, services, or organizations.
30.8
Priority Process: Diagnostic Services: Laboratory
The laboratory has a functional and supportive association with laboratories in British Columbia (BC) for
services not offered at Whitehorse General Hospital. As the Yukon Territory does not have specific legislation
governing laboratory services, BC and Health Canada and other applicable industry standards are adopted.
Appropriate equipment is available and quality measures and audits are regularly carried out and acted on as
required. The split in volumes of work for the hospital and other services is approximately 70/30%. The high
quality of reports is clearly documented, and variations from expected accuracies are promptly addressed.
In spite of almost two years of recruiting, the laboratory remains short-staffed, with the need for a quality
technologist and a microbiology charge technologist. These duties are currently fulfilled by other
technologists.
Specific opportunities for improvement exist for the consistent use of two client identifiers before providing
any service or procedure. High-risk situations occur when assumptions are made about other services'
validation of identity or when a 'familiar' client contact requires a service or procedure. It is also suggested
that members of the department could do better with hand-cleaning practices at the point of care.
Clarity remains to be established regarding professional responsibility for laboratory services offered in
Watson Lake and Dawson City. The team is congratulated on the availability of the: "guide to services",
quality, safety and other documentation for internal clients available on Sharepoint. A specific forum for
discussion of common issues affecting other departments and the laboratory would be welcomed by
laboratory staff.
QMENTUM PROGRAM
3.2.3 Standards Set: Diagnostic Imaging Services
Criteria
Priority Process: Diagnostic Services: Imaging
The organization sets clear lines of accountability for diagnostic imaging
services delivered across the organization.
1.5
The team has a management structure in place with clear reporting
relationships and lines of accountability.
3.3
The team evaluates and documents each team member's performance in an
objective, interactive, and constructive way.
3.10
Diagnostic imaging providers have a Policy and Procedure Manual that
includes detailed procedures for positioning the client for diagnostic
imaging examinations that is signed by the medical director or designate.
6.5
15.6
ROP
MINOR
MINOR
The team involves clients, families, and other organizations when
evaluating the quality of its diagnostic imaging services.
18.2
Priority Process: Diagnostic Services: Imaging
The imaging service is primarily based at a single location in the Whitehorse General Hospital. It serves as
both a hospital-based and a community access imaging service. It is well equipped with modalities including
x-ray, ultrasound, computed tomography and is in the process of implementing magnetic resonance imaging
(MRI). This last modality is being added as the result of a comprehensive needs assessment and business case
that included cost impact analyses of other areas of the health care system, such as medical travel.
The imaging department has embraced digital imaging and the use of a photo archiving system (PACS) which
allows the smooth and effective transfer of image and diagnostic information between clinicians locally and
remotely, including to secondary and tertiary care hospitals in the event of patient transfers.
There is a well-established contractual relationship with a Calgary based group of radiologists that includes
the designation of a medical director for the imaging department whose role, responsibilities and
accountabilities are clearly defined.
There are imaging services available at the Watson Lake and Dawson City hospitals, provided primarily by a
combined laboratory/imaging technician. However, since these are solo staff positions, out-of-hours imaging
is performed by nurses and physicians at these hospitals. While the training and competencies required by
competency requirements are for physicians taking x-ray images in these hospitals. This could create an area
of corporate and professional liability in the event of a patient harm event.
QMENTUM PROGRAM
nurses to perform theses additional duties are well established, it is less clear what the demonstration of
competency requirements are for physicians taking x-ray images in these hospitals. This could create an area
of corporate and professional liability in the event of a patient harm event.
QMENTUM PROGRAM
3.2.4 Standards Set: Emergency Department
Criteria
The team's goals and objectives are linked to benchmarking of bed
availability in the Emergency Department, time to admission, client
diversion to other facilities, and wait times.
2.2
The team has the workspace needed to deliver effective services in the
Emergency Department.
2.9
The interdisciplinary team follows a formal process to regularly evaluate its
functioning, identify priorities for action, and make improvements.
3.6
performance in an objective, interactive, and positive way.
4.13
Priority Process: Episode of Care
The team shares benchmark and best practice information with its partners
and other organizations.
14.5
The team monitors clients' perspectives on the quality of Emergency
Department services.
16.2
The team shares evaluation results with staff, clients, and families. 16.5
Priority Process: Organ and Tissue Donation
The organization has established clinical referral triggers to identify
potential organ and tissue donors.
9.2
The emergency departments surveyed for the Yukon Hospital Corporation (YHC) include a medium volume
emergency department ED at Whitehorse General Hospital (WGH) and a rural low-volume ED at Watson Lake
ED operates out of a site which is severely space-constrained and which is not purpose built to allow smooth
flow of emergency patients. The WLCH ED is a new, state-of-the-art facility with more than adequate space
to ensure smooth flow of patients. It also has the physical capacity to meet acute surge demands.
There are plans to build a new purpose built ED for the Whitehorse General Hospital which will mitigate some
of the flow issues associated with the current space.
The ED teams have analyzed utilization patterns by some client groups and have developed strategies to
streamline and standardize their care.
QMENTUM PROGRAM
Community Hospital (WLCH), both of which represent different environments and service models. The WGH
ED operates out of a site which is severely space-constrained and which is not purpose built to allow smooth
flow of emergency patients. The WLCH ED is a new, state-of-the-art facility with more than adequate space
to ensure smooth flow of patients. It also has the physical capacity to meet acute surge demands.
There are plans to build a new purpose built ED for the Whitehorse General Hospital which will mitigate some
of the flow issues associated with the current space.
The ED teams have analyzed utilization patterns by some client groups and have developed strategies to
streamline and standardize their care.
The emergency department (ED) teams at Whitehorse and Watson Lake sites have different criteria for
demonstrating competency to practice in the ED. At the Whitehorse General Hospital, physicians have
specific privileges based on demonstrated competency in emergency medicine via the credentialing process,
while the nursing staff members have specific skills and training in emergency care. At the Watson Lake
Community Hospital practice in the ED is not distinguished as separate from general hospital-based practice
for both physicians and nursing staff. All staff members however, have access to and participate in ongoing
ED-specific education. Although that ED has limited local access to specialist consultant services, there is
access to specialist support remotely via telephone.
Pediatric specialist support is consistently available from the British Columbia Children's Hospital. This
provides a support for the management of acutely ill pediatric patients. The ED teams have access to
diagnostic imaging information via the picture archiving communications system (PACS) which also allows
them to access imaging in anticipation of patients presenting to the ED from elsewhere in the Territory. The
ED at Whitehorse provides supportive advice to nurses providing emergency care in other Yukon communities.
It is suggested there are opportunities to enhance the support services available to and provided by the ED
teams by promoting proactive use of Telehealth.
The emergency departments (EDs) use Canadian Triage Acuity Scale (CTAS) criteria to objectively triage
patients and to ensure effective, timely care based on clinical condition. Patients are consistently seen in a
timely manner, consistent with their CTAS scores. The use of CTAS permits the teams to analyze ED
utilization by clients with different levels of clinical urgency. At Watson Lake Community Hospital, this
provides objective support for the established practice of referring CTAS 4 and 5 patients to the
community-based physician clinic. At Whitehorse, this creates the evidence base and potential to engage
community partners in designing alternate routes for urgent access to medical care. The ED teams
collaborate closely with pre-hospital emergency medical services (EMS) teams and with inter-hospital
transport teams to ensure continuity and minimize gaps in care for critically ill patients.
The ED team at Whitehorse General Hospital utilizes diagnosis and condition-specific clinical protocols and
pathways for common and high-risk conditions such as acute myocardial infarction, pediatric diabetes
ketoacidosis and alcohol withdrawal. These protocols are evidence based and are adapted for use in the
specific setting of the ED at Whitehorse.
ED clinical protocols between the three hospitals and adapting the current protocols for use in the smaller
hospital setting. There is also an opportunity to enhance the timeliness of care by creating formal delegation
to the nursing staff members at Watson Lake Community Hospital (and Dawson City when it is up and running)
to initiate therapy for common and potentially life threatening conditions such as myocardial infarctions
based on the presenting complaint.
Currently, the initiation of standard interventions such as oxygen, acetylsalicylic acid (ASA) and intravenous
(IV) insertion require a physician's order which, while easily obtainable, potentially introduces a delay in
initiating therapy. In addition, the assumption by nurses that a physician's order will be forthcoming
introduces potential professional liability. These risks could be mitigated by the adoption, in all hospitals of
the corporation, of common clinical pathways and protocols with clearly delineated professional delegation
for specific interventions and investigations.
QMENTUM PROGRAM
There are opportunities to enhance consistently high-quality emergency care across Yukon by standardizing
ED clinical protocols between the three hospitals and adapting the current protocols for use in the smaller
hospital setting. There is also an opportunity to enhance the timeliness of care by creating formal delegation
to the nursing staff members at Watson Lake Community Hospital (and Dawson City when it is up and running)
to initiate therapy for common and potentially life threatening conditions such as myocardial infarctions
based on the presenting complaint.
Currently, the initiation of standard interventions such as oxygen, acetylsalicylic acid (ASA) and intravenous
(IV) insertion require a physician's order which, while easily obtainable, potentially introduces a delay in
initiating therapy. In addition, the assumption by nurses that a physician's order will be forthcoming
introduces potential professional liability. These risks could be mitigated by the adoption, in all hospitals of
the corporation, of common clinical pathways and protocols with clearly delineated professional delegation
for specific interventions and investigations.
The ED teams provide care in a potentially high-risk area of clinical practice and respond to the care needs of
patients with all levels of clinical acuity. The teams do this consistently and use tools such as evidence-based
clinical protocols to ensure consistent quality care. The ED teams are aware of the challenges they face in
meeting the increasing service demand as well as the limitations of the services it can provide in rural and
remote communities. There will be opportunities to address some of these challenges with the proactive
design of a new ED in Whitehorse that is designed to provide care reflective of emerging best practices in
emergency care. To do this however, it will require extensive staff and public consultation to ensure that the
physical design and infrastructure supports rather than limits potential emerging models of care.
Priority Process: Organ and Tissue Donation
There is currently no formal organ donation system in the Yukon. The organization does not have the capacity
to support harvesting of organs. However, on a case by case basis, patients have been transported via air
Medivac to hospitals in BC that do have the capacity to undertake organ harvesting for transplant. While
individual clinicians are aware of the potential to transfer patients exclusively for the purpose of organ
harvesting, the more usual route toward organ donation is the transport of critically ill patients to tertiary
care hospitals where their potential as organ donors is established and the organ retrieval takes place.
QMENTUM PROGRAM
3.2.5 Standards Set: Infection Prevention and Control
Criteria
Priority Process: Infection Prevention and Control
The organization tracks infection rates; analyzes the information to identify
clusters, outbreaks, and trends; and shares this information throughout the
organization.
1.2
ROP
1.2.3 Staff and service providers are aware of the infection rates
and recommendations from outbreak reviews.
MINOR
Each policy and procedure includes up-to-date references to research and
best practice in infection prevention and control.
4.3
The organization reviews and updates its policies and procedures at least
every three years, and as new information becomes available.
4.7
The organization provides its staff, service providers, and volunteers with
access to current IPAC education materials, resources, information, and
tools.
5.6
The organization monitors compliance with its infection prevention and
control policies and procedures.
5.7
The organization evaluates its compliance with accepted hand-hygiene
practices.
6.5
ROP
6.5.1 The organization audits its compliance with hand hygiene
practices.
MAJOR
6.5.2 The organization shares results from the audits with staff,
service providers, and volunteers.
MINOR
6.5.3 The organization uses the results of the audits to make
improvements to its hand hygiene practices.
MINOR
Staff, service providers, and volunteers encourage clients, families, and
visitors to follow effective hand hygiene behaviour.
7.5
Staff and service providers use aseptic techniques when preparing,
handling, and delivering vaccines, parenterally administered medications,
total parenteral nutrition (TPN), and diagnostic media.
8.3
The organization uses the results of investigations to improve its programs,
policies or procedures, and to prevent infections from recurring.
9.6
The organization's policies and procedures address how to manage new,
rare, or problematic organisms, including antibiotic-resistant organisms.
14.4
QMENTUM PROGRAM
The principle of using the organization's data to identify areas of high risk and opportunities for improvement
is challenging given the organization's volumes. Accordingly, the infection prevention and control team may
be required to stress accepted standards as a benchmark and use their own data for feedback purposes.
The goals and methods of the team need to be well-understood by front-line users in order to obtain the best
compliance possible. There is need for a comprehensive policies and procedures manual to be completed and
incorporated into ongoing quality initiatives. It is suggested that the references supporting the manual's
content be easily accessible to reinforce suggested practices. In addition, the organization is encouraged to
examine the success of the education and training in handwashing which has been recently completed to
ensure that it has had the desired effect on behaviours and therefore, patient safety. This exercise also may
help reinforce the processes required for achieving the team's goals.
Priority Process: Infection Prevention and Control
QMENTUM PROGRAM
3.2.6 Standards Set: Medication Management Standards
Criteria
The organization has a program for antimicrobial stewardship to optimize
antimicrobial use.
Note: Beginning in January 2013, this ROP will only apply to organizations
that provide inpatient acute care services. For organizations that provide
inpatient cancer, inpatient rehab, and complex continuing care services,
evaluation of this ROP will begin in January 2014.
2.3
ROP
2.3.1 The organization implements an antimicrobial stewardship
program.
MAJOR
2.3.2 The program includes lines of accountability for
implementation.
MAJOR
2.3.3 The program is inter-disciplinary involving pharmacists,
infectious diseases physicians, infection control specialists,
physicians, microbiology staff, nursing staff, hospital
administrators, and information system specialists, as
available and appropriate.
MAJOR
2.3.4 The program includes interventions to optimize antimicrobial
use that may include audit and feedback, a formulary of
targeted antimicrobials and approved indications, staff
training, antimicrobial order sets, guidelines and clinical
pathways for antimicrobial utilization, strategies for
streamlining or de-escalation of therapy, dose optimization,
and parenteral to oral conversion of antimicrobials (where
appropriate).
MAJOR
2.3.5 The organization establishes mechanisms to evaluate the
program on an ongoing basis, and shares results with
stakeholders in the organization.
MINOR
The interdisciplinary committee establishes procedures for each step of the
medication management process.
2.4
The organization implements a comprehensive strategy for the management
of high-alert medications.
2.5
ROP
2.5.4 The policy includes procedures for storage, prescribing,
preparation, administration, dispensing, and documentation
for each high-alert medication, as appropriate.
MAJOR
2.5.5 The organization limits and standardizes concentrations and
volume options available for high-alert medications.
MAJOR
2.5.6 The organization regularly audits client service areas for
high-alert medications.
MINOR
QMENTUM PROGRAM
The interdisciplinary committee monitors compliance with each step of the
medication management process.
2.16
The interdisciplinary committee regularly reviews and updates the
formulary.
3.3
The organization provides initial and ongoing training to staff and service
providers based on their roles and responsibilities for medication
management within their scope of practice.
4.1
The organization separates look-alike, sound-alike medications; different
concentrations of the same medication; and high-alert medications in the
pharmacy and client service areas.
12.6
The organization minimizes the use of multi-dose vials in client service
areas.
12.8
The organization evaluates and limits the availability of concentrated
electrolytes to ensure that formats with the potential to cause harmful
medication incidents are not stocked in client service areas.
12.9
ROP
12.9.1 The organization completes an audit of the following
concentrated electrolytes in client service areas at least
annually:
Calcium (all salts): concentrations greater than or
equal to 10%
Magnesium sulfate: concentrations greater than 20%
Potassium (all salts): concentrations greater than or
equal to 2 mmol/mL (2 mEq/mL)
Sodium acetate and sodium phosphate: concentrations
greater than or equal to 4 mmol/mL
Sodium chloride: concentrations greater than 0.9%.
MAJOR
12.9.2 The organization avoids stocking the following concentrated
electrolytes in client service areas:
Calcium (all salts): concentrations greater than or
equal to 10%
Magnesium sulfate: concentrations greater than 20%
Potassium (all salts): concentrations greater than or
equal to 2 mmol/mL (2 mEq/mL)
Sodium acetate and sodium phosphate: concentrations
greater than or equal to 4 mmol/mL
Sodium chloride: concentrations greater than 0.9%.
MAJOR
12.9.3 When it is necessary for concentrated electrolytes to be
available in selected client service areas, the organization's
interdisciplinary committee for medication management
reviews and approves the rationale for availability and
safeguards put in place to minimize the risk of error.
MAJOR
The pharmacy routinely assesses raw materials used for compounding to
determine if they should be eliminated because they are not regularly used
or are considered dangerous.
13.1
QMENTUM PROGRAM
The organization helps provide minimal distractions, interruptions and noise
for prescribing, writing and verifying medication orders either manually or
electronically.
14.5
The pharmacist reviews prescription and medication orders within the
organization prior to administration of the first dose.
15.1
The organization has a separate area with a certified laminar air flow hood
for preparing sterile products and intravenous admixtures.
16.4
The organization labels all medication packages/units in a standardized
manner.
17.1
The organization labels all compounds and intravenous admixture
containers with, at a minimum, information on the name of the medication,
base solution, total amount of drug additives, and total volume of solution
in the container.
17.2
The pharmacy team dispenses medications in unit dose packaging. 18.2
The organization regularly evaluates its system for dispensing medications
when the pharmacy is closed and makes improvements as needed.
19.3
The organization protects the health and safety of service providers who
transport, administer, and dispose of chemotherapy medications.
20.2
The organization has a readily accessible hazardous spill kit located
wherever chemotherapy medications are dispensed and administered.
20.3
Service providers provide clients and families with information on their
medications prior to the initial dose, and when the dose is adjusted, and
document this information.
21.1
Service providers provide clients and families with information on how to
prevent medication errors.
21.2
Service providers inform clients either verbally or in writing who to contact,
and how to reach that person, if they have concerns or questions about
their medication while receiving care.
21.3
Service providers ensure that clients understand the information provided
and respond to concerns or questions clients may have about their
medication.
21.4
Service providers provide clients with written information on whom clients
can contact for questions about their medications and their availability at
the end of service or transfer of service.
21.5
Service providers seek an independent double check before administering
high-alert medications at the point of care.
23.3
The interdisciplinary committee provides staff and service providers with
regular feedback about medication errors and near misses, and risk
reduction strategies that are being implemented.
25.4
QMENTUM PROGRAM
The interdisciplinary committee prioritizes and completes medication use
evaluations.
27.6
The organization is commended on having a strong inter-professional collaborative team amongst nurses,
physicians, pharmacists, and pharmacy technicians. The organization is also commended on its
comprehensive policies and procedures established toward supporting safe medication practices and patient
safety. The organization recognizes the clinical dedication of their pharmacists and their commitment toward
continuously enhancing safe medication practices and optimizing medication therapy management, as well as
pharmacy technicians with a commitment to working collaboratively to provide quality medication dispensing
and distribution activities.
The organization is encouraged to give priority to consistently applying policies and procedures across both
Whitehorse and Watson Lake sites for assessing hours of services of pharmacy, and to align with patient
admission and medication order times. Encouragement is also offered to develop an intravenous (IV)
admixture service to assure safe medication practices with high-risk medications. The organization is also
encouraged to assess the use of automated medication dispensing cabinets for high-risk medications such as
for narcotics and controlled substances in the pharmacy area, and high-risk/high volume drug use in patient
care areas' medication night cabinet.
The organizations pharmacy team consists of 5 pharmacists (including one pharmacy manager) and 5
pharmacy technicians providing pharmacy services Monday to Fri from 8 a.m. to 4 p.m. located at Whitehorse
Hospital. After hour, on-call services are provided by pharmacists.
The pharmacy utilizes appropriate sterile compounding requirements and equipment for admixing intravenous
therapies and total parenteral nutrition. However, space for doing so in pharmacy is limited. As such, the
majority of medications are currently being admixed on patient care areas, which is not safe. The
organization has begun discussions regarding a plan for implementing a centralized intravenous admixture
service so as to assure safe medication practices and is encouraged to complete this effort so as to support
providing a dedicated intravenous admixture service for preparing sterile products and intravenous
admixtures.
Pharmacy staff provides prepackaged unit dose medications to both Whitehorse and Watson Lake, although
onsite pharmacy services are predominantly provided for Whitehorse Hospital. Medications are transported
Watson Lake Hospital. Pharmacists review medication orders and respond to drug information questions by
Watson Lake Hospital. In addition, Watson Lake Hospital also draws on telepharmacy services during busy
medication order entry times, weekdays.
The organization recognizes the clinical strengths and dedication of their pharmacists and their commitment
toward continuously enhancing safe medication practices and optimizing medication therapy management.
Pharmacists are engaged in providing direct patient care so as to optimize patients medication therapy. The
organization is encouraged to consider opportunity for pharmacists to work directly on the patient care unit
so as to be physically present with the patient care team and patients.
Pharmacy technicians are well recognized for their role through active involvement with a number of patient
safety initiatives, and medication distribution, including monitoring medication expiry dates, predominantly
at Whitehorse Hospital. The organization is encouraged to give priority to consistently applying pharmacy
presence will also help to monitor that medication related policies and procedures are consistently applied
across both Whitehorse and Watson Lake, such as with the high alert medication policy, and associated
education and training may be provided so as to support quality and safety.
When the pharmacy is closed, there is extensive use of the hospitals medication night cabinet due to the
number of patient admissions after pharmacy hours of operation. The organization has well established
policies regarding access of the Night Cabinet and after hour pharmacy services, and adheres to these.
However, there could be delays in pharmacist review of the initial order after a weekend, in particular, long
weekends. The organization is encouraged to consider ways to align pharmacy hours of services, and means
to enable a pharmacist review of medication orders in a more timely manner with patient admissions. The
organization is also encouraged to given consideration to implementing automated medication dispensing
cabinets for high use/ high risk medications, such as with narcotics and controlled substances in both the
Pharmacy and high risk/ high volume drug use in patient care areas.
The organization has an exemplary model for conducting medication reconciliation. Lead by a clinical
pharmacist, medication reconciliation is provided by an interdisciplinary team, where nurses and pharmacy
technicians are provided with training on conducting the Best Possible Medication History, and physicians are
provided with education regarding the evidence and process for conducting medication reconciliation on
admission and at each transition point in the care process.
The organization has a well established interdisciplinary Pharmacy & Therapeutics Committee with a
reporting structure to the Medical Advisory Committee. The Pharmacy & Therapeutics Committee is
encouraged to continue its work toward formalizing the organizations Formulary, and supporting criteria and
process for conducting Formulary updates and associated education and communication plan.
The organizations pharmacy manager is integrated with the national multistakeholder drug shortages
committee. He communicates new information regarding anticipated/ actual drug shortages with the
Pharmacy & Therapeutics Committees Chair and interdisciplinary team, who identify alternate therapies so
as to assure continued quality medication management and timely communications and education of
alternate therapeutic throughout the organization. The organizations work effort in the face of current
challenges with drug shortages across the country is recognized and commended.
There is commitment by the clinical pharmacists and the Chair of the Pharmacy & Therapeutics Committee,
as well as support by the Chair of the Medical Advisory Committee for establishing a formal Antimicrobial
Stewardship Program. The organization is encouraged to work toward formalizing and implementing a
program to recognize team members dedicated to providing interventions to optimize antimicrobial use, and
targeted antimicrobials and related order sets/ prerprinted orders, as well as interdisciplinary and staff
training, regarding antimicrobial use and strategies for streamlining or de-escalation of therapy, dose
optimization, and parenteral to oral conversion of antimicrobials (where appropriate), as well as utilization
audits.
QMENTUM PROGRAM
oversight of monitoring medication stock and storage at Watson Lake Hospital. The physical pharmacy
presence will also help to monitor that medication related policies and procedures are consistently applied
across both Whitehorse and Watson Lake, such as with the high alert medication policy, and associated
education and training may be provided so as to support quality and safety.
When the pharmacy is closed, there is extensive use of the hospitals medication night cabinet due to the
number of patient admissions after pharmacy hours of operation. The organization has well established
policies regarding access of the Night Cabinet and after hour pharmacy services, and adheres to these.
However, there could be delays in pharmacist review of the initial order after a weekend, in particular, long
weekends. The organization is encouraged to consider ways to align pharmacy hours of services, and means
to enable a pharmacist review of medication orders in a more timely manner with patient admissions. The
organization is also encouraged to given consideration to implementing automated medication dispensing
cabinets for high use/ high risk medications, such as with narcotics and controlled substances in both the
Pharmacy and high risk/ high volume drug use in patient care areas.
The organization has an exemplary model for conducting medication reconciliation. Lead by a clinical
pharmacist, medication reconciliation is provided by an interdisciplinary team, where nurses and pharmacy
technicians are provided with training on conducting the Best Possible Medication History, and physicians are
provided with education regarding the evidence and process for conducting medication reconciliation on
admission and at each transition point in the care process.
The organization has a well established interdisciplinary Pharmacy & Therapeutics Committee with a
reporting structure to the Medical Advisory Committee. The Pharmacy & Therapeutics Committee is
encouraged to continue its work toward formalizing the organizations Formulary, and supporting criteria and
process for conducting Formulary updates and associated education and communication plan.
The organizations pharmacy manager is integrated with the national multistakeholder drug shortages
committee. He communicates new information regarding anticipated/ actual drug shortages with the
Pharmacy & Therapeutics Committees Chair and interdisciplinary team, who identify alternate therapies so
as to assure continued quality medication management and timely communications and education of
alternate therapeutic throughout the organization. The organizations work effort in the face of current
challenges with drug shortages across the country is recognized and commended.
There is commitment by the clinical pharmacists and the Chair of the Pharmacy & Therapeutics Committee,
as well as support by the Chair of the Medical Advisory Committee for establishing a formal Antimicrobial
Stewardship Program. The organization is encouraged to work toward formalizing and implementing a
program to recognize team members dedicated to providing interventions to optimize antimicrobial use, and
targeted antimicrobials and related order sets/ prerprinted orders, as well as interdisciplinary and staff
training, regarding antimicrobial use and strategies for streamlining or de-escalation of therapy, dose
optimization, and parenteral to oral conversion of antimicrobials (where appropriate), as well as utilization
audits.
QMENTUM PROGRAM
3.2.7 Standards Set: Medicine Services
Criteria
Staff and service providers receive ongoing, effective training on infusion
pumps.
4.4
ROP
4.4.1 There is documented evidence of ongoing, effective training
on infusion pumps.
MAJOR
Before dispensing medication, a qualified team member reviews each
prescription for completeness and accuracy.
10.2
A qualified team member fills the prescription and dispenses the
medication in a timely and accurate way.
10.3
Following transition or end of service, the team contacts clients, families,
or referral organizations to evaluate the effectiveness of the transition, and
uses this information to improve its transition and end of service planning.
11.6
The team is trained to identify, reduce, and manage risks to client and staff
safety.
15.1
The team informs and educates clients and families in writing and verbally
about the client and family's role in promoting safety.
15.4
ROP
15.4.1 The team develops written and verbal information for clients
MAJOR
15.4.2 The team provides written and verbal information to clients
MAJOR
The team identifies and monitors process and outcome measures for its
medicine services.
17.1
The team monitors clients' perspectives on the quality of its medicine
services.
17.2
QMENTUM PROGRAM
The team compares its results with other similar interventions, programs,
or organizations.
17.3
The team uses the information it collects about the quality of its services to
identify successes and opportunities for improvement, and makes
improvements in a timely way.
17.4
There is a high level of collaboration amongst all team members. The team is supported with the education
and training it needs in order to be effective in their role.
Staff members are committed to providing safe and quality patient care services. The clinical nurse leader
works closely with the clinical care managers to identify skill needs and to develop a comprehensive, as well
as individual, plan for addressing the identified needs to support staff members to be successful in their
roles. The organization is commended for recognizing the need for implementing an e-learning program to
empower staff members and further support a sense of accountability to work toward goal achievement.
The team works collaboratively and effectively and draws on one another's knowledge and skills toward their
goal for providing safe, quality patient care.
The Yukon Hospital Corporation has comprehensive quality, safety and risk assessment in providing clinical
care processes and strives to achieve this organization-wide by way of collaboration among clinical care
managers and team members. The organization recognizes the importance of supporting staff members with
the infrastructure and tools they need to perform their work and is striving to address implementation of
tools such as wireless structure, and online education tools.
The medicine services team has identified and implemented measures for reducing risks that could lead to
patients and staff harm. There is a genuine interest in supporting team members. The service collaborates
across the organization in identifying areas of improvement for enhancing quality and staff and patient
safety. The organization is encouraged to engage patients in their care planning and medication therapy
management. The organization is also encouraged to consider options for reducing potential problems with
handling and storing and dispensing of medications on the patient care area.
QMENTUM PROGRAM
3.2.8 Standards Set: Mental Health Services
Criteria
The team has access to the resources needed to regularly deliver safe and
quality mental health services.
2.5
Where infusion pumps are used, staff and service providers receive ongoing,
effective training on infusion pumps.
4.4
ROP
on infusion pumps.
MAJOR
performance in an objective, interactive, and constructive manner.
4.12
The team assesses and monitors clients for risk of suicide. 7.5
ROP
7.5.5 The team documents the implementation of the treatment
and monitoring strategies in the client's health record.
MAJOR
The team follows the organization's process to identify, address, and record
ethics-related issues.
8.10
The team uses standardized clinical processes to minimize service
duplication.
10.7
The organization's process for selecting guidelines includes seeking input
from clients, families, staff, and service providers about the applicability
of the guidelines to client recovery.
15.2
The team regularly monitors clients' perspectives on the quality of its
mental health services.
18.2
The team identifies and monitors process and outcome measures for its
mental health services.
18.3
The team shares evaluation information with staff, clients, and families. 18.7
QMENTUM PROGRAM
The organization provides acute mental health services on the Secure Medical Unit. In addition, services are
provided in the emergency department (ED). The organization has accountability for the acute episode of
care and program leaders work well with their community partners for health promotion and prevention
initiatives and follow-up care with community based programming.
There is good understanding of the community needs based on a recent needs assessment survey and data
available from the Canadian Health Survey results. This information is incorporated into planning. There are
unique challenges for Yukon Health Corporation (YHC) however, given that the full spectrum of services for
this patient population does not fall under the mandate of the organization but rather, rests with the Yukon
Department of Health and Social Services.
The program leadership is commended for initiating a new territorial multi-agency committee to plan for
quality improvement opportunities across the continuum of care for the clients served. Goals and objectives
have been identified for this service and are aligned with the organization's strategic directions.
There are opportunities to select and monitor key performance metrics for the program to guide quality
improvement and monitor progress. Standard 2.5 speaks to the need for adequate resources to deliver safe
quality mental health care. The size of the Secure Medical Unit is small and does not lend itself to some of
the programming one can see in the larger facilities. To address this, program staff members will link with
their community partners, and community mental health workers will come to the unit to see clients and
staff from within the First Nations Health Program are well-connected to this service. The Secure Medical
Unit is well designed, secured and has two seclusion rooms. Should space become available, the unit could
benefit from a patient lounge for client groups if appropriate, or for client socialization, consistent with
standard 2.3.
The services provided for mental health under the Yukon Hospital Corporation (YHC) are provided by an
interdisciplinary health care team made up of a psychiatrist, general practitioner and nurses and social
workers and therapists on occasion and representatives from the First Nations Health Program. There is
evidence that there is a process in place to ensure that health professionals maintain their competencies and
credentialing, and ongoing professional development and training is made available to staff.
QMENTUM PROGRAM
and the organization is encouraged to promote further integration of this new form with current practice.
The health care team in the Secure Medical Unit works closely with their colleagues that are providing
community-based services. Information is shared within the circle of care to enhance care delivery. It is
noted that there is an opportunity to increase the use of evidence-informed guidelines for the service. The
use of the alcohol withdrawal protocol has been adopted across the organization and guides practice at both
Whitehorse General Hospital (WGH) and the Watson Lake Community Hospital (WLCH). A noted strength in
the program is the evidence of interdisciplinary, client-focused care planning. The client Kardex is
well-designed to promote this interdisciplinary team work and care planning.
The leadership of the Secure Medical Unit (SMU) pays close attention to the importance of safety for both the
clients served and the staff working on the unit. Historically, the mental health inpatient population was
located on the general medical unit however, in the past few years they were able to create a secure unit
which enhanced safety for patients, visitors and staff. There is evidence that required organizational
practices (ROPs) pertaining to patient safety are well integrated into patient care delivery on this unit.
Staff members are familiar with the organization's adverse reporting system and acknowledged that their
manager reports back to them on outcomes related to investigations undertaken. One staff member's
suggestion that an enhancement to the current practice include reporting out to a larger audience was well
received. Standard 18.2 speaks to the organization monitoring client feedback on their perspective of the
quality of care. Historically, the organization has used the National Research Corporation (NRC) Picker tool
however, it is moving ahead with a new and more prospective assessment tool. The unit (SMU) is encouraged
to seek out opportunities to enhance the patient experience by using the feedback received in the
plan-do-study-act (PDSA) cycles for quality improvement.
The community needs assessment has identified there is a significant need for mental health and alcohol and
drug services. The mandate for the Yukon Hospital Corporation (YHC) focuses on the acute episode of care.
Partnerships have been built with community partners to optimize care for their mutual clients across the
continuum. Urgent crisis and emergent care is available to this population within the services provided and
there is good evidence of strong interdisciplinary team work. During the on-site survey the team
demonstrated using a holistic approach to care delivery incorporating physical, psychological, spiritual and
social aspects of care. This is particularly strong in the First Nations Health Program.
The organization has recently developed a comprehensive suicide assessment form. The adoption of this form
as the means with which the assessment is conducted and the results reported has not been completely
embraced. Information related to the outcome of a suicide risk assessment was evident in the client record
reviewed however, the form was not used. This inconsistency in practice could lead to miscommunication,
QMENTUM PROGRAM
3.2.9 Standards Set: Obstetrics Services
Criteria
The team's goals and objectives for obstetrics services are measurable and
specific.
2.2
3.9
The team receives ongoing, effective training on all infusion pumps for staff
and service providers.
4.5
ROP
on infusion pumps.
MAJOR
Team leaders evaluate and document each team member's performance in
an objective, interactive, and positive way.
4.9
The team has a policy and procedure for sponge and needle counts for pre-
and post-vaginal births.
9.10
The organization has an infant feeding policy. 11.3
Following transition or end of service, the team contacts clients, families,
or referral organizations to evaluate the effectiveness of the transition, and
uses this information to improve its transition and end-of-service planning.
12.5
18.2
ROP
MINOR
MINOR
The team monitors clients and families' perspectives the quality of its
obstetrics services.
20.3
QMENTUM PROGRAM
As the sole birthing service in Yukon the obstetrical team is in a central position with respect to the care of
all expectant mothers across the Territory. In keeping with this mandate, the team receives antenatal
records for all expectant mothers at 20 weeks gestation and again at 36 weeks gestation. This allows the
team to anticipate the clinical needs of specific patients as well as to ensure appropriate staffing and
resources to support patients in labour.
The team is well equipped and uses a single-room birthing approach that supports families and minimizes
disruption to the birthing journey. Decision making and planning both for service delivery and clinical
practice are interdisciplinary and collaborative processes.
The obstetrics team functions in an interdisciplinary manner. Nursing staff members have documented
training and experience in maternity care. Family physicians have specific privileges for delivering babies and
these are based on documented proof of competency by way of the credentialing process. Obstetricians
function in a consultant role as well as providing direct patient care. The team is supported by anesthesia
providing continuous availability of epidural analgesia and cesarean section delivery. The team participates in
ongoing education and skills enhancement with programs such as advanced labour and risk management
(ALARM) and locally developed continuing education. This team is high-functioning and collegial and
supportive.
The obstetrics team practices as an interdisciplinary team of physicians and nurses. The team uses practice
guidelines for peri-partum care and utilizes the BC Reproductive Care Program as an external source of
expertise and evidence-based guideline development. The care offered to labouring and post-partum mothers
is holistic and respectful of individual wishes and beliefs, while maintaining a focus on safety and
evidence-based care. Patients report positive experiences in that they feel informed, empowered and
respected during the birthing process.
The team uses the BC Reproductive Care Program documentation to maintain patient labour and delivery
records. The team has access to prenatal records for the majority of patients presenting to the maternity unit
for labour and delivery. This allows the team to be proactive in planning care for specific patients as well as
planning resources and staffing. There is collaborative information sharing between community-based
physicians, the obstetrical team and other service providers such as public health as well as with the First
Nations Health Program. This allows for smooth transitions of care as well as effective planning and delivery
of care.
QMENTUM PROGRAM
unit in the Territory, there are opportunities to enhance patient care and to provide a high degree of
assurance to Territorial residents about the quality of the birthing service using consistent measurement and
benchmarking.
Patient feedback about the obstetrics service tends to be complimentary and to reflect a high degree of
satisfaction with the service provided. Individually and anecdotally, nursing and medical staff members are
aware of the outcomes for their patients. However, the service does not currently measure, monitor,
evaluate and benchmark to ensure the quality of the service it provides. Given that this is the sole birthing
QMENTUM PROGRAM
3.2.10 Priority Process: Surgical Procedures
Delivering safe surgical care, including preoperative preparation, operating room procedures, postoperative
recovery, and discharge
Criteria
Standards Set: Operating Rooms
1.8
The team's orientation includes training on all infusion pumps. 2.3
ROP
2.3.1 There documented evidence of ongoing, effective training on
infusion pumps.
MAJOR
Team leaders monitor and meet each team member's ongoing education,
training, and development needs.
2.4
Team members follow a dress code within the surgical suite. 8.1
The organization uses a smoke evacuation system when an electrosurgical
unit is operated.
9.4
When transporting contaminated equipment and devices, the organization
complies with applicable regulations, controls environmental conditions,
and uses clean and appropriate bins, boxes, bags and transport vehicles.
12.7
The team uses flash sterilization in the operating room only in an
emergency, and never for complete sets or implantable devices.
12.8
The team selects and monitors specific performance indicators for the
operating room and its services.
14.3
The team sets performance goals and objectives and measures their
achievement.
14.4
The team benchmarks or compares its results with other similar
interventions, programs, or organizations.
14.5
Standards Set: Surgical Care Services
The team regularly reviews its services and makes changes as needed. 1.5
The team develops standardized processes and procedures to improve
teamwork and minimize duplication.
3.4
QMENTUM PROGRAM
3.7
Staff and service providers receive ongoing, effective training on infusion
pumps.
4.4
ROP
on infusion pumps.
MAJOR
The team monitors and meets each team member's ongoing education,
training, and development needs.
4.7
performance in an objective, interactive, and positive way.
4.8
The team assesses each client's risk for developing a pressure ulcer and
implements interventions to prevent pressure ulcer development.
7.9
ROP
7.9.5 The team has a system in place to measure the effectiveness
of pressure ulcer prevention strategies, and uses results to
make improvements.
MINOR
Before dispensing medication, a qualified team member reviews each
prescription for completeness and accuracy.
10.2
A qualified team member fills the prescription and dispenses the
medication in a timely and accurate way.
10.3
The organization has a process to select evidence-based guidelines for
surgical care services.
14.1
The team reviews its guidelines to make sure they are up-to-date and
reflect current research and best practice information.
14.2
The team's guideline review process includes seeking input from staff and
service providers about the applicability of the guidelines and their ease of
use.
14.3
The team's research activities for surgical care services meet applicable
research and ethics protocols and standards.
14.4
The team shares benchmark and best practice information with its partners
and other organizations.
14.5
The team monitors clients' perspectives on the quality of its surgical care
services.
16.2
The team compares its results with other similar interventions, programs,
or organizations.
16.3
The team uses the information it collects about the quality of its services to
identify successes and opportunities for improvement, and makes
improvements in a timely way.
16.4
QMENTUM PROGRAM
The Whitehorse General Hospital has a relatively small volume surgical service however, the team has made
significant advances in introducing and reinforcing accepted standards. In that sense it matches surgical
services with much larger volumes. There remains a risk that the services progress could be stalled. The
service is encouraged to continue to adopt recognized policies and processes to ensure patient quality and
safety is of the highest quality and safety, as well as track, analyze and understand their own data.
QMENTUM PROGRAM
Instrument Results Section 4
As part of Qmentum, organizations administer instruments. Qmentum includes three instruments (or
questionnaires) that measure governance functioning, patient safety culture, and quality of worklife. They are
completed by a representative sample of clients, staff, senior leaders, board members, and other
stakeholders.
4.1 Governance Functioning Tool
The Governance Functioning Tool enables members of the governing body to assess board structures and
processes, provide their perceptions and opinions, and identify priorities for action. It does this by asking
questions about:
Board composition and membership
Scope of authority (roles and responsibilities)
Meeting processes
Evaluation of performance
Accreditation Canada provided the organization with detailed results from its Governance Functioning Tool prior
to the on-site survey through the client organization portal. The organization then had the opportunity to address
challenging areas.
Data collection period: January 12, 2013 to April 1, 2014
Number of responses: 12
Governance Functioning Tool Results
% Disagree % Neutral % Agree
Organization Organization Organization
* Canadian
Average
%Agree
1 We regularly review, understand, and ensure
compliance with applicable laws, legislation and
regulations.
8 8 83 89
2 Governance policies and procedures that define our
role and responsibilities are well-documented and
consistently followed.
17 0 83 93
3 We have sub-committees that have clearly-defined
roles and responsibilities.
8 0 92 93
4 Our roles and responsibilities are clearly identified
and distinguished from those delegated to the CEO
and/or senior management. We do not become
overly involved in management issues.
0 0 100 90
5 We each receive orientation that helps us to
understand the organization and its issues, and
supports high-quality decision-making.
17 25 58 89
Instrument Results 67 Accreditation Report
QMENTUM PROGRAM
* Canadian
Average
%Agree
6 Disagreements are viewed as a search for solutions
rather than a win/lose.
8 8 83 92
7 Our meetings are held frequently enough to make
sure we are able to make timely decisions.
0 8 92 94
8 Individual members understand and carry out their
legal duties, roles and responsibilities, including
sub-committee work (as applicable).
17 8 75 93
9 Members come to meetings prepared to engage in
meaningful discussion and thoughtful
decision-making.
0 17 83 92
10 Our governance processes make sure that everyone
participates in decision-making.
8 33 58 90
11 Individual members are actively involved in
policy-making and strategic planning.
8 8 83 88
12 The composition of our governing body contributes
to high governance and leadership performance.
8 0 92 89
13 Our governing bodys dynamics enable group
dialogue and discussion. Individual members ask for
and listen to one anothers ideas and input.
8 0 92 92
14 Our ongoing education and professional development
is encouraged.
17 33 50 87
15 Working relationships among individual members and
committees are positive.
8 8 83 96
16 We have a process to set bylaws and corporate
policies.
0 0 100 91
17 Our bylaws and corporate policies cover
confidentiality and conflict of interest.
0 0 100 95
18 We formally evaluate our own performance on a
regular basis.
0 8 92 78
19 We benchmark our performance against other
similar organizations and/or national standards.
25 33 42 66
20 Contributions of individual members are reviewed
regularly.
33 17 50 61
QMENTUM PROGRAM
* Canadian
Average
%Agree
21 As a team, we regularly review how we function
together and how our governance processes could be
improved.
8 8 83 77
22 There is a process for improving individual
effectiveness when nonperformance is an issue.
36 27 36 53
23 We regularly identify areas for improvement and
engage in our own quality improvement activities.
8 42 50 78
24 As a governing body, we annually release a formal
statement of our achievements that is shared with
the organizations staff as well as external partners
and the community.
0 8 92 81
25 As individual members, we receive adequate
feedback about our contribution to the governing
body.
33 25 42 64
26 Our chair has clear roles and responsibilities and
runs the governing body effectively.
8 8 83 92
27 We receive ongoing education on how to interpret
information on quality and patient safety
performance.
25 33 42 78
28 As a governing body, we oversee the development of
the organizations strategic plan.
0 0 100 92
29 As a governing body, we hear stories about clients
that experienced harm during care.
17 33 50 81
30 The performance measures we track as a governing
body give us a good understanding of organizational
performance.
8 17 75 88
31 We actively recruit, recommend and/or select new
members based on needs for particular skills,
background, and experience.
33 17 50 84
32 We have explicit criteria to recruit and select new
members.
25 25 50 79
33 Our renewal cycle is appropriately managed to
ensure continuity on the governing body.
0 11 89 86
QMENTUM PROGRAM
* Canadian
Average
%Agree
34 The composition of our governing body allows us to
meet stakeholder and community needs.
0 9 91 91
35 Clear written policies define term lengths and limits
for individual members, as well as compensation.
0 8 92 92
36 We review our own structure, including size and
sub-committee structure.
20 0 80 86
37 We have a process to elect or appoint our chair.
17 33 50 90
*Canadian average: Percentage of Accreditation Canada client organizations that completed the instrument
from July to December, 2013 and agreed with the instrument items.
QMENTUM PROGRAM
4.2 Patient Safety Culture Tool
Organizational culture is widely recognized as a significant driver in changing behavior and expectations in order
to increase safety within organizations. A key step in this process is the ability to measure the presence and
degree of safety culture. This is why Accreditation Canada provides organizations with the Patient Safety Culture
Tool, an evidence-informed questionnaire that provides insight into staff perceptions of patient safety. This tool
gives organizations an overall patient safety grade and measures a number of dimensions of patient safety
culture.
Results from the Patient Safety Culture Tool allow the organization to identify strengths and areas for
improvement in a number of areas related to patient safety and worklife.
Accreditation Canada provided the organization with detailed results from its Patient Safety Culture Tool prior to
the on-site survey through the client organization portal. The organization then had the opportunity to address
areas for improvement. During the on-site survey, surveyors reviewed progress made in those areas.
Data collection period: October 17, 2012 to July 31, 2013
Minimum responses rate (based on the number of eligible employees): 136
QMENTUM PROGRAM
0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e

P
o
s
i
t
i
v
e

(
%
)
Senior leadership
support for safety
(valuing safety)
Patient safety learning
culture
Supervisory leadership
support for safety
Communication
barriers/talking about
errors
Overall perception of
patient safety
60% 56% 63% 55% 52%
68% 59% 71% 53% 68%
* Canadian Average
Legend
Patient Safety Culture Tool: Results by Patient Safety Culture Dimension
QMENTUM PROGRAM
4.3 Worklife Pulse
Accreditation Canada helps organizations create high quality workplaces that support workforce wellbeing and
performance. This is why Accreditation Canada provides organizations with the Worklife Pulse Tool, an
evidence-informed questionnaire that takes a snapshot of the quality of worklife.

Organizations can use results from the Worklife Pulse Tool to identify strengths and gaps in the quality of
worklife, engage stakeholders in discussions of opportunities for improvement, plan interventions to improve the
quality of worklife and develop a clearer understanding of how quality of worklife influences the organization's
capacity to meet its strategic goals. By taking action to improve the determinants of worklife measured in the
Worklife Pulse tool, organizations can improve outcomes.
Data collection period: September 23, 2012 to December 5, 2012
Minimum responses rate (based on the number of eligible employees): 190
Accreditation Canada provided the organization with detailed results from its Worklife Pulse Tool prior to the
on-site survey through the client organization portal. The organization then had the opportunity to address areas
for improvement. During the on-site survey, surveyors reviewed progress made in those areas.
QMENTUM PROGRAM
0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e

P
o
s
i
t
i
v
e

(
%
)
Job Coworkers
Training and
Development
Immediate
Supervisor
Senior
Management
68%
Safety and
Health
Overall
Experience
56% 75% 68% 49% 69% 72%
74% 64% 81% 75% 63% 77% 67%
* Canadian Average
Legend
Worklife Pulse: Results of Work Environment
QMENTUM PROGRAM
Measuring client experience in a consistent, formal way provides organizations with information they
can use to enhance client-centred services, increase client engagement, and inform quality
improvement initiatives.
Prior to the on-site survey, the organization conducted a client experience survey that addressed the
following dimensions:
Respecting client values, expressed needs and preferences,including respecting client rights,
cultural values, and preferences; ensuring informed consent and shared decision-making; and
encouraging active participation in care planning and service delivery
Sharing information, communication, and education,including providing the information that
people want, ensuring open and transparent communication, and educating clients and their
families about the health issues
Coordinating and integrating services across boundaries,including accessing services,
providing continuous service across the continuum, and preparing clients for discharge or
transition
Enhancing quality of life in the care environment and in activities of daily living,including
providing physical comfort, pain management, and emotional and spiritual support and
counselling
The organization then had the chance to address opportunities for improvement, and to discuss
related initiatives with surveyors during the on-site survey.
Client Experience Tool
Client Experience Program Requirement
Conducted a client experience survey using a survey tool and approach that
meets accreditation program requirements
Unmet
Provided a client experience survey report(s) to Accreditation Canada Unmet
QMENTUM PROGRAM
Organization's Commentary Section 5
After the on-site survey, the organization was invited provide comments to be included in this
report about its experience with Qmentum and the accreditation process.
Accreditation provides a visible commitment by the Yukon Hospital Corporation (YHC) to the quality of
patient care and services, a safe environment and continual work done to reduce risks to patients and
staff. Accreditation Canada standards serve as an effective quality evaluation and management tool.
We use best practice standards provided by Accreditation Canada as part of our process for determining
and acting on organizational priorities, setting our strategy and supporting goals.
Recently we were evaluated by five experienced surveyors who shared their time and expertise about
safe, quality hospital care. We appreciated the time they spent learning from front line staff and
management and the effort they put into evaluating Whitehorse General Hospital and Watson Lake
Community Hospital to ensure a comprehensive report was provided. The report acknowledged the good
work that has been done by our staff and provided recommendations that we will integrate into our
continuous quality improvement efforts moving forward. The Yukon Hospital Corporation identifies
priorities for action which encompasses corporate and front line initiatives covering a range of work
from capital planning, human resources planning, patient and organizational safety, risk management
and best practices implementation.
YHC has worked diligently to serve the health care needs of all Yukoners over the past three years.
Ambitious capital projects including the building of two new community hospitals and a staff residence
have been completed. In a joint effort we are working with the Yukon Government on planning for an
expansion to the Whitehorse General Hospital. This project includes the implementation of the new MRI
program, redesign of the emergency department and other necessary improvements. These projects
were made possible through the hard work and dedication of our staff and partners and we are proud of
the infrastructure development which ensures the best possible facilities and services are available
closer to home for our patients.
With patients as our first priority we are enthusiastic about recent efforts to improve the manner in
which we receive feedback on the patient experience, and we continually strive to keep patients and
families involved and informed in their care. One of the most significant recent improvements is the
implementation of wireless internet within the Whitehorse General Hospital which will help us to more
efficiently and effectively provide and receive information focused on improving patient care.
The Board of Trustees and our Leadership team are committed to ensuring we are aligned and
understand the risks and improvement opportunities throughout the organization. Through regular
reporting and evaluation, and a strong commitment to quality and safety, we ensure resources are
appropriately allocated to support our strategic goals. We also recognize the need to continue with the
development of benchmarks and indicators that are meaningful and robust in support of effective
decision making at all layers of the organization.
We are proud of the improvements we have seen at YHC over the past three years and look forward to
continuing to improve quality and safety throughout the organization. We understand the need to use
meaningful information, evaluate the implementation of our programs and continually learn as we
develop our clinical and administrative programs and processes. One of our values is that "we commit to
pursing continuous improvement and innovation to achieve exemplary performance". We appreciate the
support and input from Accreditation Canada as we continually strive in our mission to provide Safe and
Excellent Hospital Care.
Organization's Commentary 76 Accreditation Report
QMENTUM PROGRAM
Qmentum Appendix A
Health care accreditation contributes to quality improvement and patient safety by enabling a health
organization to regularly and consistently assess and improve its services. Accreditation Canada's Qmentum
accreditation program offers a customized process aligned with each client organization's needs and priorities.
As part of the Qmentum accreditation process, client organizations complete self-assessment questionnaires,
submit performance measure data, and undergo an on-site survey during which trained peer surveyors assess their
services against national standards. The surveyor team provides preliminary results to the organization at the end
of the on-site survey. Accreditation Canada reviews these results and issues the Accreditation Report within 10
business days.
An important adjunct to the Accreditation Report is the online Quality Performance Roadmap, available to client
organizations through their portal. The organization uses the information in the Roadmap in conjunction with the
Accreditation Report to ensure that it develops comprehensive action plans.
Throughout the four-year cycle, Accreditation Canada provides ongoing liaison and support to help the
organization address issues, develop action plans, and monitor progress.
Following the on-site survey, the organization uses the information in its Accreditation Report and Quality
Performance Roadmap to develop action plans to address areas identified as needing improvement. The
organization provides Accreditation Canada with evidence of the actions it has taken to address these required
follow ups.
Five months after the on-site survey, Accreditation Canada evaluates the evidence submitted by the organization.
If the evidence shows that a sufficient percentage of previously unmet criteria are now met, a new accreditation
decision that reflects the organization's progress may be issued.
Evidence Review and Ongoing Improvement
Action Planning
Qmentum 7 Accreditation Report
QMENTUM PROGRAM
Priority Processes Appendix B
Priority processes associated with system-wide standards
Priority Process Description
Communication Communicating effectively at all levels of the organization and with external
stakeholders
Emergency Preparedness Planning for and managing emergencies, disasters, or other aspects of public
safety
Governance Meeting the demands for excellence in governance practice.
Human Capital Developing the human resource capacity to deliver safe, high quality services
Integrated Quality
Management
Using a proactive, systematic, and ongoing process to manage and integrate
quality and achieve organizational goals and objectives
Medical Devices and
Equipment
Obtaining and maintaining machinery and technologies used to diagnose and
treat health problems
Patient Flow Assessing the smooth and timely movement of clients and families through
service settings
Physical Environment Providing appropriate and safe structures and facilities to achieve the
organization's mission, vision, and goals
Planning and Service Design Developing and implementing infrastructure, programs, and services to meet
the needs of the populations and communities served
Principle-based Care and
Decision Making
Identifying and decision making regarding ethical dilemmas and problems.
Resource Management Monitoring, administration, and integration of activities involved with the
appropriate allocation and use of resources.
Priority processes associated with population-specific standards
Chronic Disease Management Integrating and coordinating services across the continuum of care for
populations with chronic conditions
Population Health and
Wellness
Promoting and protecting the health of the populations and communities
served, through leadership, partnership, innovation, and action.
Priority Processes 7 Accreditation Report
QMENTUM PROGRAM
Priority processes associated with service excellence standards
Blood Services Handling blood and blood components safely, including donor selection, blood
collection, and transfusions
Clinical Leadership Providing leadership and overall goals and direction to the team of people
providing services.
Competency Developing a skilled, knowledgeable, interdisciplinary team that can manage
and deliver effective programs and services
Decision Support Using information, research, data, and technology to support management
and clinical decision making
Diagnostic Services: Imaging Ensuring the availability of diagnostic imaging services to assist medical
professionals in diagnosing and monitoring health conditions
Diagnostic Services:
Laboratory
Ensuring the availability of laboratory services to assist medical professionals
in diagnosing and monitoring health conditions
Episode of Care Providing clients with coordinated services from their first encounter with a
health care provider through their last contact related to their health issue
Impact on Outcomes Identifying and monitoring process and outcome measures to evaluate and
improve service quality and client outcomes
Infection Prevention and
Control
Implementing measures to prevent and reduce the acquisition and
transmission of infection among staff, service providers, clients, and families
Medication Management Using interdisciplinary teams to manage the provision of medication to clients
Organ and Tissue Donation Providing organ donation services for deceased donors and their families,
including identifying potential donors, approaching families, and recovering
organs
Organ and Tissue Transplant Providing organ transplant services, from initial assessment of transplant
candidates to providing follow-up care to recipients
Organ Donation (Living) Providing organ donation services for living donors, including supporting
potential donors to make informed decisions, conducting donor suitability
testing, and carrying out donation procedures
Point-of-care Testing
Services
Using non-laboratory tests delivered at the point of care to determine the
presence of health problems
Priority Processes Accreditation Report
QMENTUM PROGRAM
Primary Care Clinical
Encounter
Providing primary care in the clinical setting, including making primary care
services accessible, completing the encounter, and coordinating services
Surgical Procedures Delivering safe surgical care, including preoperative preparation, operating
room procedures, postoperative recovery, and discharge
Priority Processes 8 Accreditation Report

Rapport D'accrétidation de La Régie Des Hôpitaux Du Yukon 2014 Préparé Par Agrément Canada (En Anglais)

Caricato da

Informazioni sul documento

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Rapport D'accrétidation de La Régie Des Hôpitaux Du Yukon 2014 Préparé Par Agrément Canada (En Anglais)

Caricato da

Copyright:

Formati disponibili

Accreditation Report

Yukon Hospital Corporation

Potrebbero piacerti anche