1. Accreditation What is a ROP?
A Required Organizational Practice (ROP) is an essential practice that we must have in place to enhance patient
safety and minimize risks to patients. In order to receive Accreditation with Exemplary Standing, we must meet all ROPs that are applicable to the organization. ROPs are the key to successful Accreditation!
Karen Roberts & Jackie Veneruz

2. ROPS Hand Hygiene Audit Hand Hygiene Education and Training
Work Place Violence prevention
VTE Prophylaxis
Two Client Identifiers
Med Reconciliation as an Organizational Priority
Information Transfer
Fall Prevention Strategy
Infusion Pump Training
Pressure Ulcer Prevention
Client and Family Role in Safety
Client Safety Education and Training
Infections Rates
Surgical Checklist
Sterilization Process
Adverse Event Disclosure/Reporting

3. Hand Hygiene Why is it important?
Hand hygiene is a critical element of an adequate infection control program in a health care setting.
Education and training on hand hygiene addresses the importance of hand hygiene by;
Preventing infections
Demonstrating proper techniques
Influencing hand-hygiene behaviour.

4. Hand Hygiene- Audit’s At TBRHSC we…
Have a hand hygiene auditing process involving trained auditors and standardized audit tools.
Provide on-the-spot feedback to healthcare providers whenever appropriate.
Share the results of the auditing process with units/programs and appropriate stakeholders on a regular basis
Use the results of the audits to make improvements to hand hygiene practices.
Publicly report hand hygiene compliance rates to the Ministry of Health and Long Term Care (MOHLTC)on an annual basis.

5. Hand Hygiene- Education/Training
At TBRHSC we…
Provide education and training on hand hygiene at staff orientations, in-services, quality huddles, via e- learning, simulations, and annual core competency certifications.
Use visual messaging and reminders like home grown videos, prompts, posters to educate the importance of hand hygiene.
Conduct regular assessment and recommendations relating to hand hygiene resources.
Provide written materials (brochures/fact sheets) and discuss importance
I.E Med Rec

7. Top questions surveyors may ask about this ROP
1. Why do we need to audit hand hygiene compliance?
2. What are the “four moments” for hand hygiene?
3. How is hand hygiene compliance monitored?
4. What are the two methods of performing hand hygiene?
5. Why is hand hygiene so important?
1. Why do we need to audit hand hygiene compliance? make improvements to hand hygiene practices
2. What are the “four moments” for hand hygiene? 1. Before Entering the pt room/or contact. 2. Before Aseptic procedure 3. After body fluid exposure risk 4. After the pt or leaving the pt environment.
3. How is hand hygiene compliance monitored? auditing process
4. What are the two methods of performing hand hygiene? Soap & Water, and Alcohol base hand rub
5. Why is hand hygiene so important? Prevent infection

8. Med Rec Why is it important?
Medication reconciliation provides a structured process for accurate and complete review and assessment of medication information at transitions of care;
Admission
Transfer
Discharge
It promotes patient safety by reducing potential for medication discrepancies such as;
Omission
Duplication
Unintentional dosing changes.

9. Med Rec
At TBRHSC we…
Have implemented medication reconciliation in specific areas of the hospital.
Have medication reconciliation tools to facilitate further roll out in ambulatory care areas.
Conduct routine audits to measure the rate of reconciliation at admission, transfer and discharge.
Have a medication reconciliation policy and procedure that is accessible on the hospital intranet site.

10. Top three questions surveyors may ask about this ROP
1. What is medication reconciliation?
2. When should medication reconciliation be performed?
3. Is there a medication reconciliation policy in place?