1. Debriefing Presentation Covenant Health
October 15-20, 2017
Accredited by

2. Surveyor Team
David Keselman
Marilyn Barrett (Team Leader)

3. Overview of Survey Process
# of Priority Processes: 5
# of Sites: 10

4. This is a calling, not a job!
(Physician)

5. Highlights Since Last Survey
Successes:
Med Rec well embedded into practice
ROPs being met; maintaining high compliance rate
Resident & Family Councils active
Challenges:
Turnover and recruitment challenges in middle management
Ability to integrate information technology (hybrid charts, multiple systems that do not talk to each other)
Large span of control and impacts on operational deliverables (e.g. PA’s, Audits, Monitoring)

6. Overall Observations Strengths: Dedicated staff/leaders
High levels of teamwork and inter-professional collaboration
Resident/Family councils active
Areas of high satisfaction
Volunteers

7. Overall Observations Challenges:
Recruitment & Retention of qualified staff and leaders, particularly in more rural areas
Lean support to leaders (e.g. Clinical Education, OH&S, HR, etc.)
Communication: inconsistency in mode of communication and information transfer (at sites and in between sites)
Aging Infrastucture in some sites

8. Overview by Quality Dimension
Met
Unmet
N/A
Total
Accessibility 15 1 16
Appropriateness
109 7
116
Client-centred Services 90 4 94
Continuity
Efficiency 2
Population Focus
Safety 53 55
Worklife 3 18

9. Overview by Standard Section
Met
Unmet
N/A
Total
Hospice, Palliative, End-of-Life Services
152 7
159
Long Term Care
151 10
161

10. Accreditation Canada Priorities
Patient Safety
Strengths:
Clinical Safety Coordinators
Quality Indicator Audits
Significant amount of education/training on patient safety
Challenges:
Span of control of managers/coordinators
Recruitment and retention in vacancies
# of unmet ROP(s): 0

11. Accreditation Canada Priorities
Client-and Family-Centred Care
Strengths:
Organization has recognized this is important
Patient and Resident Engagement Framework
Policy & Procedures
Challenges:
Implementing
Embedding
Evaluating

12. Accreditation Canada Priorities
Ethics
Strengths:
Robust framework
Ethics committees throughout the organization at the local level
Access to expertise when required
Challenges:
Continuing to maintain and increase awareness

13. Accreditation Canada Priorities
Risk Management
Strengths:
Developing a culture of prevention
Significant auditing
Incident reporting well done in some sites
Challenges:
Ensuring roles and responsibilities; span of control
Reporting of Near misses

14. Accreditation Canada Priorities
Quality Improvement
Strengths:
Participating in research activities
Working to address quality issues raised by residents and families (e.g. related to food; activities)
Monthly reporting of corporate quality indicators
Challenges:
More staff engagement in quality improvement activities
Continue monitoring and reporting progress
Evaluate improvement to food and activities (especially in smaller and remote sites)

15. Next Steps Accreditation report Accreditation decision
Submission of supplementary evidence

16. Please note:
This presentation is intended to present preliminary findings only.
Accreditation Canada reserves the right to alter or revise any of this material based on our further review.
Accreditation Canada recommends that the information contained within this “debriefing” be reserved for internal use only.

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