Information from the on-site investigation and other data obtained from the organization was used to prepare this accreditation report. The following sets of standards were used to assess the organization's programs and services during the on-site investigation.
Overview by Required Organizational Practices
Summary of Surveyor Team Observations
The team reconciles the client's medication with the involvement of the client, family or caregiver at the start of the service when medication management is an essential part of care. The team combines the client's medication with the involvement of the client, family or relatives at
Priority Process Results for System-wide Standards
Priority Process: Planning and Service Design
The MUHC staff members and leadership shared many examples of using the literature and learning and guiding best practices. In the future, the MUHC will work with other hospitals and services to decant some outpatient and inpatient beds.
Priority Process: Governance
The board may receive hard copy board packets or may access the packet electronically through a secure portal. The board works to ensure that the need to balance the budget does not compromise the quality and safety of patient care.
Priority Process: Resource Management
Priority Process: Human Capital
With the transition plan and harmonization of services, it is hoped to help balance the workload in the future. Volunteers are currently managed at the various facilities they support, with some managers responsible for more than one site.
Priority Process: Integrated Quality Management
Medication reconciliation has been in various stages of planning and implementation at the MUHC for several years. This quality award is presented by the chairman of the board and a vice-president of the Quebec Blue Cross.
Priority Process: Principle-based Care and Decision Making
Priority Process: Communication
A number of changes have already taken place in the information system, and more are planned in the future. Several policies are outdated and a thorough document management system is required and tentatively planned for the future.
Priority Process: Physical Environment
The senior housekeeping manager is aware of the issue and has increased the number of pick-up times, but apparently more adjustments are needed. An ongoing issue witnessed by a number of inspectors conducting clinical tracers was the condition of medicine refrigerators on some units.
Priority Process: Emergency Preparedness
Templates with key indicators are completed to ensure consistency between all sites at the hospitals. Staff members in key areas of the hospitals have received non-violent crisis training to ensure they have the ability to respond to code white situations. The upcoming expansion provides an opportunity for the MUHC to ensure that appropriate decontamination areas are available for emergency patients in the event of a disaster.
Priority Process: Patient Flow
De même, des discussions sont en cours avec des partenaires des Centres de santé et sociaux (CSSS), des espaces de réadaptation, de soins palliatifs.
Priority Process: Medical Devices and Equipment
Managers and employees involved in reprocessing have completed recognized training in reprocessing and sterilization. Since then, all new staff hired from outside the organization have been required to have a university-level certification in reprocessing. Thirty-three of the 100 senior associates to date have completed the 1,000-hour online certification course.
Service Excellence Standards Results
Standards Set: Ambulatory Care Services
There are appropriate interdisciplinary teams in the outpatient settings of the McGill University Health Center (MUHC). Ambulatory care teams are encouraged to establish appropriate target populations for receiving formal medications, focusing on clients for whom drug treatment is an important component of care. We encourage the team to continue developing clinical pathways and managing medical conditions as appropriate in outpatient settings.
Standards Set: Ambulatory Systemic Cancer Therapy Services
In the mature programs, when there is an increase in volume in one site, a corridor of services is available from one center to another with the aim of not delaying care. There is a willingness to develop an electronic card in the near future in collaboration with the new hospital. On this site there is continuous overflow of rubbish bins during the working day and/or at the beginning of the following working day.
Standards Set: Biomedical Laboratory Services
Standards Set: Blood Bank and Transfusion Services
Standards Set: Cancer Care and Oncology Services
Specifically, an external review of the service conducted two years ago recommended that two additional registered nurses (RNs) be hired to support oncology services at the Montreal Children's Hospital. Patients and family members who were interviewed expressed their appreciation for the care provided and were particularly appreciative of the quick response time provided by nursing staff when called. Employees are aware of policies and procedures and the importance of adhering to them.
Standards Set: Case Management Services
The case management team for children with complex conditions is dedicated and the relationships between team members are fluid. Another team is involved with geriatric patients, in emergency situations and the hospital to implement a geriatric approach in acute care. Furthermore, access to medication lists in the patient's numbered file is not easy, and searching for it creates delays.
Standards Set: Critical Care
Where possible, the team accommodates the presence of the client's family members in the room when performing emergency procedures. The team has a process to identify and reduce risks to team members while delivering critical care. The team providing neonatal intensive care at Montreal Children's and Royal Victoria hospitals are informed about how to identify, reduce and manage patient and staff safety risks.
Standards Set: Diagnostic Imaging Services
The potential for their privacy to be compromised exists, as conversations between the patient and sonographer on each side of the curtain can be overheard by the other.
Standards Set: Emergency Department
Adult emergency services at the Royal Victoria site and pediatric emergency services at the Montreal Children's Center were evaluated during this on-site study. The adult emergency services at the Royal Victoria site and the pediatric emergency services at the Montreal Children's Center were evaluated during this on-site study. The adult emergency services at the Royal Victoria Hospital and the pediatric emergency services at the Montreal Children's Center were evaluated during this on-site study.
Standards Set: Hospice, Palliative, and End-of-Life Services
They have almost unlimited access to the patient and are included in conversations between the patient and staff members if the patient wishes. The nursing staff members respond quickly when patients request their presence and this is greatly appreciated by the patient. The patient's psychosocial well-being is considered extremely important and psychiatrists and psychologists are available to help when needed.
Standards Set: Infection Prevention and Control
Accurate processes are in place for all Infection Prevention and Control (IPAC) concerns and activities. There are still problems with sharing responsibilities for cleaning, disinfecting equipment and areas, and controlling the quality of cleaning. In some areas there are not enough to be easily accessible to employees and service providers.
Standards Set: Laboratory and Blood Services
There is a laboratory manager who is responsible for overseeing clinical activities inside and outside the laboratory. There is a comprehensive external quality assurance program that provides staff members with feedback on their performance. Staff members are concerned about the current practice of not making up shifts for short and long term absences.
Standards Set: Long-Term Care Services
The residents who met on site during the survey expressed great satisfaction with the help and support they receive and refer to the staff members as family. The scheduled replacement of infusion pumps available to the LTC unit may be an opportunity to institute more systematic and continuous training for staff. Observations made on site during the survey indicate that staff members do not consistently ensure beyond all doubt that, by using dual identification, the correct medication is provided to the correct resident.
Standards Set: Managing Medications
The organization has and follows a process to manage the return of medications to the pharmacy. The organization has implemented an antimicrobial stewardship program to optimize the use of antimicrobials and is leading the implementation of this program in other hospitals in Quebec. Aligning these systems as the organization continues its journey to an electronic health record will be valuable.
Standards Set: Medicine Services
The teams are encouraged to continue to evaluate their performance as they move toward new models of care in the future. Teams are encouraged to continue implementing medication reconciliation across all medical units. All departments of medicine are encouraged to move forward with the Transforming Care at the Bedside (TCAB) project.
Standards Set: Mental Health Services
In the emergency department, there are often two to 18 patients waiting to be admitted to the inpatient beds of the mental health department. In addition to the renovation of the mental health unit, equipment was updated and additional supplies were made available. Forty percent of the nurses in the mental health program are over the age of sixty.
Standards Set: Obstetrics Services
The team regularly evaluates its services and ensures that they are closely aligned with the strategic direction of the organization. The team completed the three modules of the Efficiently Managing Obstetric Risk (MORE ob) program. Team leadership is encouraged to formalize this process so that team members receive regular feedback on their performance.
Standards Set: Organ and Tissue Donation Standards for Deceased Donors
Patients interviewed on site during the study indicated that the recording room is old and dated, but clean and acceptable. The team follows guidelines established during team discussions, and practice is updated regularly. Medical staff members have an annual review and this does not include 360-degree feedback, which is another potential area for improvement.
Standards Set: Organ and Tissue Transplant Standards
During the interviews, the team found that there is a lack of resources in the area of mandatory data reporting. Patients indicate that the team provides exemplary care and psychosocial support for their needs during the transplant process. Team members track and monitor performance, both internally and as part of their mandatory reporting requirements.
Standards Set: Organ Donation Standards for Living Donors
Standards Set: Point-of-Care Testing
Immediately prior to performing the point-of-care test, the healthcare professional verifies that the POCT device is in proper working order through a quality control check. Health professionals who provide POCT collect and record quality control data for each point-of-care test. The laboratory director or qualified healthcare professional reviews the quality control data on a monthly basis and makes improvements as needed.
Standards Set: Telehealth Services
Fine-tuning issues when using this technology, such as lag time, are permanent and successful in many cases. Ethical issues have not yet been raised, but members and partners are aware of the formal process should the need arise in the future. These requests are then facilitated by the coordination team and the applicant will receive confirmation of the telehealth booking.
Priority Process: Surgical Procedures
The team uses flash sterilization in the operating theater only in an emergency, and never for complete sets or implantable devices. While the team generally coordinates services with other peri-operative services, there are issues at the Montreal General Hospital (MGH) site, with surgeons able to keep patients in the post-anesthesia care unit (PACU) for 24 hours for monitoring rather than admit them to the unit and have them discharged the next day. It is suggested that the team include a review of the booking practice in its goals and objectives to reduce the number of last minute cancellations and delays.
Governance Functioning Tool
8 Individual members understand and carry out their statutory duties, roles and responsibilities, including subcommittee work (as appropriate). 24 As a governing body, every year we publish an official statement about our achievements, which we share with the organization's staff and external partners and the community. 30 The performance measurements that we follow as an administrative body allow us to have a good understanding of the organization's performance.
Patient Safety Culture Tool
Canadian Average: Percentage of Accreditation Canada client organizations that completed the instrument from July to December 2012 and agreed with the instrument items.
Worklife Pulse Tool
Measuring customer experience in a consistent, formal way provides organizations with information they can use to improve customer-centric services, increase customer engagement, and inform quality. Respects client values, expressed needs and preferences, including respecting client rights, cultural values and preferences; ensuring informed consent and shared decision-making; and encourage active participation in care planning and service delivery. 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
The inspection team provides preliminary results to the organization at the end of the on-site investigation. Following the on-site investigation, the organization uses the information in its accreditation report and Quality Performance Roadmap to develop action plans to address areas identified as requiring improvement. Five months after the on-site investigation, Accreditation Canada evaluates the evidence submitted by the organization.
Evidence Review and Ongoing ImprovementAction Planning
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. The organization provides Accreditation Canada with evidence of the actions it has taken to address these required follow-ups.
Priority processes associated with system-wide standards
Priority processes associated with population-specific standards
Priority processes associated with service excellence standards