Information from the on-site survey as well as other data obtained from the organization was used to prepare this accreditation report. The following set of standards were used to assess the organization's programs and services during the on-site investigation.
Overview by Required Organizational Practices
Hand hygiene education and training (Infection prevention and control standards for community-based organizations). Infection Prevention and Control Standards for Community-Based Organizations).
Summary of Surveyor Team Observations
The Tlicho Community Services Agency is well aware of the health and wellness trends in their community and the impact on community service planning and delivery for the future. The commitments to maximize all aspects of the accreditation process to this end were clear everywhere.
Detailed Required Organizational Practices
Detailed On-site Survey Results
Priority Process Results for System-wide Standards
Priority Process: Governance
The Board of Directors has demonstrated a good understanding of financial pressures and an excellent focus on service delivery and. This reflects the board structure and community representation model in place.
Priority Process: Planning and Service Design
Information on health status is routinely collected by public health for territories and presented in an easy-to-use format. During numerous conversations with the leaders and the Board, it was noticed that financial resources are scarce in some areas. Discussions with all stakeholders noted that attention is being paid to potential alternative sources of income and areas for improving efficiency.
An example noted was the development of a working group to support information technology development and changes. The Tlicho Community Services Agency Health and Social Services is committed to moving from a model of professional dependency to a wellness model of health. The integration of health and social services with education services provided excellent opportunities for collaboration.
Furthermore, the continued commitment to an integrated system of territorial programs and services supports broad initiatives to promote health.
Priority Process: Resource Management
Priority Process: Human Capital
The team has not yet developed process and outcome measures related to work life and the work environment. The team interviewed noted awareness of the Patient Safety Culture "Bundle" for CEO and Senior Leaders and use the framework to develop action plans aimed at addressing issues raised by staff. It is suggested that the team implement their plans and continue to use the Worklife Pulse to monitor the outcomes of this work.
There are plans to expand this training in collaboration with the Canadian Patient Safety Institute. The recruitment processes used by the organization work in conjunction with the Territorial Human Resources Department. Processes and policies are in place to ensure that job descriptions (including reporting relationships) are updated regularly.
Also supporting retention was the community's efforts to support residents in their education.
Priority Process: Integrated Quality Management
To address the four key strategic priorities, a healthy and safe work environment must be created. An abuse, maltreatment, neglect policy and support training programs are in place for all new staff. The staff patient safety culture study noted, however, that many staff are reluctant to report incidents.
As quality improvement and risk management are still developing, a prospective analysis of patient safety has not yet been performed. The organization is encouraged to select a patient safety area and complete a prospective analysis that can contribute to improvement activities. There is now an opportunity to improve these reports and focus on the reporting process, outcome indicators and related measures in key areas of patient safety.
As the quality improvement program matures, results from quality and patient safety activities can be incorporated.
Priority Process: Principle-based Care and Decision Making
The information gathered from the trend analysis of ethical issues will be very useful in informing quality and learning activities in the future.
Priority Process: Communication
Priority Process: Physical Environment
Priority Process: Emergency Preparedness
Priority Process: People-Centred Care
Priority Process: Patient Flow
Priority Process: Medical Devices and Equipment
Service Excellence Standards Results
Standards Set: Child, Youth, and Family Services - Direct Service Provision
The program has a great mix of staff with different skills and experience to make it an effective program for the community. The child's voice is always heard, respected and acknowledged in all aspects of the circle of care. There are many opportunities for children and young people to be exposed to the appropriate use of social media.
There are many partners who have worked together, for example the RCMP, schools and many more to support and protect the child and youth. The staff supports the families to understand the court and legal system for the best interests of the child and youth. The organization is to be commended for the commitment and dedication of their staff in support and protection of the youth and children in this community.
The next step would be to develop meaningful, measurable indicators that the organization can use to track progress.
Standards Set: Community-Based Mental Health Services and Supports - Direct Service Provision
Interdisciplinary case conferences are conducted, however, the organization is encouraged to work with staff toward developing and implementing an integrated case management model to ensure continuity, consistency, and inclusiveness in care plans. Therefore, the organization is encouraged to continue to work collaboratively with key community partners and stakeholders in building localized capacity across the mental well-being and continuum of care (eg, emergency response training, peer and peer programs). land-based, detoxification/stabilization/transition beds supported by wraps around teams). Customer rights and responsibilities are reviewed upon receipt and customers are encouraged to complete satisfaction surveys.
The mental health program has yet to be integrated into an electronic medical record system (eg WOLF) and is also separate from the child and family MATRIKS system, which presents challenges in developing baseline indicators to measure effectiveness of programs and services over time. to measure. In addition, the organization is encouraged to support the team in the development and implementation of standardized forms (intake, assessment, suicidal risk, discharge, etc.), across mental health program and service streams. The organization is encouraged to continue to actively involve staff and clients in patient safety incident reporting and follow-up, in addition to workshops and awareness activities (campaigns) for the ethics framework.
Clients have expressed reluctance to share anything in writing due to their oral or verbal cultural practice, so consideration may be given to adapting incident reporting and ethics processes to accommodate the population served.
Standards Set: Home Care Services - Direct Service Provision
The organization is encouraged to continue to grow computer literacy across all team members in preparation for a new electronic health record system. There is evidence that each time the team provides services, they identify the client using two identifiers. There is a medication reconciliation policy available that identifies the roles and responsibilities of the team members handling the process.
There is evidence that the team works well together, and they feel supported with each other. Customer safety and quality improvement are two concepts that the team embraces and commits to deliver better services. Some of the data the team collects includes allergy documentation, medication reconciliation and.
The organization is encouraged to continue its quality and safety journey and develop indicators that are relevant to the team and track data overtime to better identify trends.
Standards Set: Infection Prevention and Control Standards for Community-Based Organizations - Direct Service Provision
Standards Set: Long-Term Care Services - Direct Service Provision
The team emphasized the importance of working together with the same goal to better serve their residents and their families, and the importance of communication when working in a small and close-knit community. The organization is encouraged to further increase the computer knowledge of all team members in preparation for a new electronic patient record system interRAI. When a resident moves into the facility, a full orientation is given on what to expect, their rights and responsibilities, and an introduction to team members is provided.
Evidence exists where a group provides services, treatment or medication to its residents to identify the resident using two approved client identifiers. The organization is encouraged to involve its staff, residents and families in exploring other options for recreational activities. The team attends regular safety meetings to discuss topics such as hand hygiene, patient safety, maintaining workplace safety, infection prevention and control, and occupational health and safety regulations.
The organization works with residents, their families and their community to continuously improve services.
Standards Set: Medication Management Standards - Direct Service Provision
Standards Set: Point-of-Care Testing - Direct Service Provision
Standards Set: Remote/Isolated Health Services - Direct Service Provision
Specific client health information is provided by the organization during care transitions, but it is a paper-based system, which presents a challenge for clients returning after discharge from, for example, acute care and/or treatment outside the community. In the absence of reliable data, monitoring trends across programs and professions remains a challenge. Although many quality improvement activities were observed, they were mostly informal in nature (to the benefit of local areas), so there is room for progress in working with communities to develop culturally inclusive indicators.
There is much evidence of informal continuous quality improvement activities, however, very little written evidence to support the generation of knowledge or monitoring of trends over time. Education and awareness activities related to continuous quality improvement and the development of culturally inclusive and safe community-based indicators can be supported with additional human resources to support localized learning among staff and clients. Clients spoke of their culture being spoken rather than written, so the organization is encouraged to bridge knowledge gaps by leveraging local resources (eg, team members who currently translate can become 'quality ambassadors').
In addition, the organization could leverage partner resources (territorial ethics) and post-secondary institutions to support best practices in risk management, ethical decision-making, patient safety (fall prevention), and quality improvement activities created in communities.
Instrument Results
Governance Functioning Tool (2016)
Individual members understand and carry out their legal duties, roles and responsibilities, including subcommittee work (as applicable). As a team, we regularly review how we operate together and how our management processes can be improved. As a governing body, we regularly identify areas for improvement and are involved in our own quality improvement activities.
The performance metrics we track as a governing body give us a good understanding of organizational performance. We actively recruit, recommend and/or select new members based on specific skill, background and experience needs. Canadian average: Percentage of Canadian accreditation client organizations that completed the instrument from July to December 2018 and agreed with the instrument items.
Canadian Average: Percentage of Accreditation Canada client organizations that completed the tool from July to December 2018 and agreed with the tool items.
Canadian Patient Safety Culture Survey Tool
Canadian Average: Percentage of Accreditation Canada client organizations that completed the tool from January to June 2019 and agreed with the tool items.
Worklife Pulse
Organization's Commentary
Appendix A - Qmentum
Action Planning
Appendix B - Priority Processes
Priority processes associated with system-wide standards
Priority processes associated with population-specific standards
Priority processes associated with service excellence standards