1. On-site Survey Debriefing CASA Child, Adolescent and Family Mental Health 21/10/2013 - 24/10/2013

2. © Accreditation Canada/Agrément Canada The On-Site Survey  A comprehensive review of governance, leadership, clinical programs and services  Incorporates multiple sources of evidence Observations from tours and direct care provision Discussions with staff, clients, families, board, community partners, and stakeholders Review of documentation 2

3. © Accreditation Canada/Agrément Canada 3 Overview of the On-Site Survey  21/10/2013 - 24/10/2013  Genevieve Corbin  Doreen Fey  Kevin Hayes

4. © Accreditation Canada/Agrément Canada 4 Preliminary Results  The results presented here are preliminary.  Results will be reviewed by Accreditation Canada for internal consistency. Therefore, it is recommended that these results be reserved for internal use.  The Accreditation Report, issued by Accreditation Canada within 10 days, will provide final results and the accreditation decision.

5. © Accreditation Canada/Agrément Canada 5 Overall Strengths  Innovation ie new Front Door Services  Effective Outreach  Generosity of Spirit  Organizations Report Card and Targets

6. © Accreditation Canada/Agrément Canada 6 Overall Areas for Improvement  Leadership Development  Infection Prevention and Control practices  Implement medication rec fully across programs  Policy Development cycle

7. © Accreditation Canada/Agrément Canada 7 Overview by Quality Dimension Quality DimensionMetUnmetN/ATotal Population Focus (Working with communities to anticipate and meet needs)316037 Accessibility (Providing timely and equitable services)181019 Safety (Keeping people safe)104820132 Worklife (Supporting wellness in the work environment)577165 Client-centred Services (Putting clients and families first)500151 Continuity of Services (Experiencing coordinated and seamless services)1200 Effectiveness (Doing the right thing to achieve the best possible results)1823315230 Efficiency (Making the best use of resources)261027

8. © Accreditation Canada/Agrément Canada 8 Overview by Standard Section Standard SectionMetUnmetN/ATotal Governance726078 Leadership112271140 Infection Prevention and Control541730101 Customized Managing Medications461552 Community-Based Mental Health Services and Supports Standards13410135 Telehealth Services624167

9. © Accreditation Canada/Agrément Canada High-priority criteria focus on …  Patient safety  Ethics  Risk management  Quality improvement 9

10. © Accreditation Canada/Agrément Canada 10 Patient safety  Strengths Client and family education Hand Hygiene Audits  Areas for improvement Report on progress to staff, leaders and Board

11. © Accreditation Canada/Agrément Canada 11 EthicsEthics  Strengths Staff survey to understand the importance of ethics process Research ethics framework has been developed  Areas for improvement: Complete the action plan Develop framework

12. © Accreditation Canada/Agrément Canada 12 Risk management  Strengths Job hazard analysis Health and safety audit  Areas for improvement Complete the risk assessment process Develop risk framework and risk mitigation plan CASA Center

13. © Accreditation Canada/Agrément Canada 13 Quality improvement  Strengths Focus on consultation during improvement activities Evaluation at a glance  Areas for improvement Integrate the framework Prioritize improvement projects

14. © Accreditation Canada/Agrément Canada Reaching an accreditation decision  Surveyor findings are forwarded to Accreditation Canada  Decision is made by the Accreditation Decision Committee, in collaboration with surveyors as required  Accreditation Decision Committee ensures consistency in application of decision guidelines  Decision guidelines include compliance with standards criteria, Required Organizational Practices, and instrument thresholds 14

15. © Accreditation Canada/Agrément Canada Accreditation Achievement  Participating in accreditation is a significant achievement  Demonstrates commitment to quality and safety  Best results achieved through continued integration of accreditation into ongoing quality initiatives 15

16. © Accreditation Canada/Agrément Canada 16 Next Steps  Accreditation Report, with accreditation decision, issued within 10 days  Over the next five months, submit evidence of action taken to address gaps  Continue to action opportunities for improvement

17. © Accreditation Canada/Agrément Canada 17 Contact us Accreditation Canada 1150 Cyrville Road Ottawa, ON Canada K1J 7S9 Tel: 1-800-814-7769 or 613-738-3800 Fax: 1-800-811-7088 or 613-738-3755 www.accreditation.ca Accreditation Canada does not accept responsibility for the accuracy of this material if is presented by anyone other than an authorized Accreditation Canada representative.

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