Information for Staff Accreditation 2016 WRHA Cardiac Sciences Program

Information for Staff
WRHA Cardiac Sciences Program
Accreditation 2016
The Language of Accreditation
To help you prepare for the upcoming Site Visit by Accreditation Canada, scheduled for
April 17-22, 2016 here is a crash course in some of the terminology.
Qmentum: Qmentum is the name of the
accreditation process used by Accreditation
Canada. It combines the words “quality” and
“momentum” which helps align accreditation with
the organization’s ongoing quality improvement
process. The Qmentum process consists of a
self-assessment questionnaire (SAQ done Feb
2015), development of our Quality Plan (updated
Feb 2016), an onsite survey (happening April
20, 2016) and follow-up actions for
improvement.
Standards: Accreditation Canada has
established 62sets of standards for service
provision and practice within healthcare. There
are FOUR sets of standards used to evaluate
the Cardiac Sciences Program. They include
Perioperative Services (includes Cardiac OR,
Cardiac Surgery Inpatient Unit, Heart Catheterization
and Cardiac Implant Labs), Critical Care, Medicine,
and Ambulatory Care. Our SAQ was completed
by our staff in February 2015 and were based on
these 4 sets of standards.
Surveyors: Surveyors, or accreditors as they
are sometimes called, are peer reviewers. They
hold leadership positions in healthcare in other
provinces across Canada and are trained by
Accreditation Canada to conduct site visits in
their areas of expertise. They assess the
processes and performance of health
organizations and compare them to national
standards and then make recommendations for
change. Surveyors are dedicated professionals
who give generously of their time and expertise
to help organizations achieve quality
improvement.
Site Visit: Surveyors from Accreditation
Canada will be in Winnipeg from April 17-22,
2016.

ICCS will be surveyed from 0800-1200.
The Required Organizational Practice
(ROP) of Medication Reconciliation will
be one of their focuses. This ROP
needs to be completed on admission,
transfer and discharge from the unit.

The Perioperative Services (which include
Cardiac Surgery Inpatient Unit, Heart
Catheterization and Cardiac Implant Labs)
will also be surveyed from 0800-1200.

Clinic areas will be surveyed from 13001600. The areas include Y2, Asper CR1
and CR3.
The Surveyors will be using a Tracer
methodology (see below) which means that staff
from sites other than those selected for site
visits may still have some direct contact with the
Surveyors, so all staff need to be aware of and
prepared for Accreditation.
Priority Process: Priority processes are
key processes within an organization that reflect
critical areas and systems that are known to
have significant impact on the quality and safety
of care and services. In total there are 26
priority processes being reviewed:

Eleven are system wide processes
including communication, emergency
preparedness, integrated quality
management, and patient flow.

One is a population specific process
called population health and wellness.

Fifteen are service excellence
processes including blood services,
diagnostic services and imaging,
episode of care, medication
management, and surgical procedures.
The Cardiac Sciences Program will be surveyed
on April 20, 2016. Three surveyors will be on
site visiting the following areas:
Information for Staff, Accreditation 2016
#2 March 14, 2016
ROP (Required Organizational
Practice): An ROP is a necessary practice
http://home.wrha.mb.ca/quality/TracerTraining.php (to
view video; use Google Chrome or Mozilla Firebox)
that organizations must have in place to
enhance patient/patient safety and minimize
risk. As of 2016 there are 33 ROPs
incorporated into the 62 set of standards! The
2016 ROP Handbook can be found at
http://home.wrha.mb.ca/quality/rops.php
Tracer Process:
REVIEW
client files and
documents
Tracers:
A tracer is a quality improvement
tool to help surveyors determine if standards are
met and to identify areas needing improvement.
During a tracer, surveyors observe and interact
with a wide variety of staff, patients, and
stakeholders to gather evidence about the
quality and safety of care and services in
aparticular area. Tracers help them evaluate
both clinical (direct patient care) and
administrative (governance, leadership,
management) processes.
The tracer method is flexible and responsive,
allowing surveys to observe and interact directly
with organizations staff in their working
environment. As they conduct a tracer,
surveyors rate each criterion using “yes” (the
criterion has been met), “no” (the criterion has
not been met), or “not applicable” (the criterion
does not apply).
There are 2 types of Tracers:


Clinical Tracers use an open patient
record and interview staff, patients and
families, as well as observation of
practice to trace the path of care and
services delivered to a specific patient.
Administrative Tracers follow an
initiative rather than a patient. This
tracer can follow a policy, a process
such as patient flow, infection
prevention and control, safety and
access to services.
Tracer methodology is NOT used to evaluate
individual staff competency or the care
provided to particular patients/patients. It
simply uses a real patient record to track and
observe processes used within our program.
RECORD
what is read, heard
and seen
Tracer
Activities
TALK and LISTEN
Individual interviews/
discussions and group
discussions
OBSERVE
direct observation and
tours
Some SAMPLE Questions a
Surveyor MAY ask:

What changes have been made to improve
patient/patient safety in your organization?

When must you wash your hands with soap
and water?

What is your role in the event of a fire or
other disaster?

What is the procedure for reporting a safety
problem?

How were you trained in infection control,
fire safety and emergency management?

How is patient/patient specific information
protected in your organization?

How is a patient’s right to privacy ensured?

Please explain the process that a family
member or patient would follow to report a
complaint or concern.

Describe your process for handling
medications brought in from home by
patients?

How often do employees receive a formal
evaluation (CARS) in your organization?
A great resource is the tracer videos!! These
short videos highlight the trace method.
Information for Staff, Accreditation 2016
#2 March 14, 2016