1. Debriefing Presentation North Bay Regional Health Centre 25/11/2012 - 30/11/2012

2. Surveyor Team Régis Vaillancourt Cholly Boland Anita Marie Harris
Darlene J. Furlong
Heather Garnett
Constantine Bubela

3. Overview of Survey Process
# of Priority Processes: 27
# of Sites: 9

4. Highlights since Last Survey
Successes:
Merged organization/new building
Values focus
Addressed most areas of concern from last survey
Reorganization/new leadership
Volunteer Ambassadors
Challenges:
Repeat ROP
Financial

5. Overall Observations Strengths: Partnerships Workplace atmosphere
Communication – internal and external
Innovation
My Meds
ER infection follow-ups
‘ER Admissions Nurse’
Ambitious plans

6. Overall Observations Challenges: Ensuring all sites ‘feel connected’
Consistent operational planning and monitoring
Regular performance appraisals for all workers

7. Overview by Quality Dimension
Met
Unmet
N/A
Total
Population Focus (Working with communities to anticipate and meet needs) 66 10 76
Accessibility (Providing timely and equitable services)
121 1
122
Safety (Keeping people safe)
578 22 11
611
Worklife (Supporting wellness in the work environment)
174 4
178
Client-centred Services (Putting clients and families first)
205
206
Continuity of Services (Experiencing coordinated and seamless services) 74
Effectiveness (Doing the right thing to achieve the best possible results)
864 44
919
Efficiency (Making the best use of resources) 78 82
2160 86
2268

8. Overview by Standard Section
Met
Unmet
N/A
Total
Diagnostic Imaging Services
123 4
131
Governance 73 1 78
Leadership
127 10 3
140
Obstetrics Services
145
147
Infection Prevention and Control
102
103
Ambulatory Care Services
116
121
Biomedical Laboratory Services 52
Blood Bank and Transfusion Services 59
Community-Based Mental Health Services and Supports Standards
124
135

9. Overview by Standard Section
Met
Unmet
N/A
Total
Critical Care
127 3 1
131
Emergency Department
129 2
132
Laboratory and Blood Services
176
Managing Medications
119 15
135
Medicine Services
102
105
Mental Health Services
101 9
111
Operating Rooms 99
Rehabilitation Services 92 10
103
Reprocessing and Sterilization of Reusable Medical Devices 95 4

10. Overview by Standard Section
Met
Unmet
N/A
Total
Substance Abuse and Problem Gambling Services
100 3 1
104
Surgical Care Services 99 5
2160 86 22
2268

11. Accreditation Canada Priorities
Patient Safety
Strengths:
Dedicated resources
Focussed within programs
Engagement
Challenges:
Two identifiers before meds
Patient/family role in safety
Reporting/evaluation of surgical checklist

12. Accreditation Canada Priorities
Ethics
Strengths:
Resources to resolve ethical situations
Staff awareness of options
Plans to raise awareness
Challenges:
Board awareness and application in all decisions
Consistent awareness across in all areas

13. Accreditation Canada Priorities
Risk Management
Strengths:
REDS incident reporting system
Awareness of clinical risks within programs, especially those in Mental Health
Plans for enterprise risk management
Challenges:
No comprehensive enterprise-wide program

14. Accreditation Canada Priorities
Quality Improvement
Strengths:
Dedicated resources
Focus at board and leadership
Incident reviews
Commitment to ‘More Time to Care ’
Challenges:
Monitoring and reporting on metrics and targets in all areas

15. Next Steps ▪ Accreditation Decision (10 days). ▪ Accreditation report.
▪ Submission of evidence of action taken.
▪ Continuous Quality Improvement.
Congratulations !

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 further review and input by Accreditation Canada.
Accreditation Canada recommends that the information contained within this “debriefing” be reserved for internal use only.

17. For further information, please contact
Accreditation Canada
1150 Cyrville Road
Ottawa, ON Canada K1J 7S9
Tel: or
Fax: or
Website:
Only Accreditation Canada representatives may deliver this presentation. Accreditation Canada does not accept responsibility for others who may present this material.

18. The leader in raising the bar for health quality
Le leader qui hausse la barre en matière de qualité de santé

19. Thank you !