During the week of November 21, our CIUSSS will be visited by 
Accreditation Canada. The presence of this Health Standards Organization and its evaluation are part of the continuous quality improvement cycle of our CIUSSS. Inscribed in the Act Respecting Health Services and Social Services, the evaluation allows us to take stock of our performance and demonstrate that we are meeting the required organizational practices (ROPs) and standards of excellence on a daily basis in all of our sectors of activity.
We will be proud to highlight the daily work of our CIUSSS’s care and service teams, as Accreditation Canada's visitors focus on the following teams and themes:
| Teams | Themes for all |
| Mental health and addiction | Leadership standards and governance for safe services |
| Acute care services (physical health) | Infection prevention and control standards and reprocessing |
| General services | Medication safety standards |
| Youth services | Telehealth |
| 31 required organizational practices (ROPs) |
Every week until November, the progress of our preparations for Accreditation Canada’s visit will be updated for employees in the Daily Bulletin. Our weekly communications will outline how we are meeting the standards; it will also highlight the successes of our teams. And keep an eye out for quizzes and prizes!
Culture of safety
Several initiatives have been put in place in recent months to ensure safe services for our users and patients:
| Appropriate time slots | Modernized equipment |
| Audits | Partnerships |
| Communication tools or methods | Policies and procedures |
| Decision support tools | Posters and flyers |
| Electronic prescriptions | Standardized evaluation grid |
| Enhanced service pathways | Support and coaching |
| Implementation of guidelines | Teams of experts |
| Improved methods of care and services | Telehealth visits |
| Training and meetings |
Daily communications, publications in the 360o newsletter, podcasts and our Internet and intranet sites are other great ways to share these initiatives.
What about you? How do you provide quality, safe, person-centered services? How do your team and partners report events, discuss issues, participate in improvements and celebrate results?
We invite you to review the Required Organizational Practices (ROP) bulletins on safety culture available on the CIUSSS intranet site. You can also participate in quizzes and draws.
Infection prevention and control
Many practices for infection prevention and control (IPAC) are well established in our CIUSSS and have proved to be successful.
| Compliance rates for hand hygiene practices are meeting all targets. | Annual training and certification in hand hygiene is available on the intranet and is incorporated into orientation for new employees. |
| A CIUSSS-wide signage system outlines sanitation measures that are now in place: hand-washing, physical distancing and wearing a mask. | Infection rates are tracked by the IPAC team. |
| Best practices for cleaning and disinfection are monitored daily by the Technical Services team. | The IPAC committee and team report regularly, as required by statute, to the Risk Management Committee. |
| Best practices for screening and immunization are in place. | Sterilization of medical equipment is centralized at the Jewish General Hospital. |
| Best practices are monitored, standardized and evaluated across all facilities in our CIUSSS. |
In this context, how do you and your team provide services that meet best IPAC practices? How do you report outbreaks and ensure that your teams are mobilized to deploy appropriate practices to control outbreaks? How do you ensure continuous process improvement?
We invite you to review the Required Organizational Practices (ROP) bulletins on infection prevention and control that are available on the CIUSSS’s intranet site. You can also participate in quizzes and draws.
Medication management and safety
Several best practices have been put in place to ensure optimal and safe medication management within our CIUSSS.
| A central committee and local medication safety committees assess risk situations, implement safe practices and monitor their effectiveness and compliance. | A policy on the management of high-alert medications includes procedures for the storage, ordering, preparation, administration, dispensing and recording of each of these medications. |
| A list of high-alert medications is attached to the CIUSSS list (concentrated electrolytes, narcotics, heparin, antineoplastic, insulin). This policy includes all required safety measures and a list of independent double checks. | High alert medications are stored separately and are clearly identified by:
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| High alert medication information is posted, where applicable, on CIUSSS units and departments and on the intranet. Training is also provided. | High-alert medication concentrations and volume options are limited and standardized. |
| High-alert medications are routinely checked on the wards. | Ongoing education and training is provided to team members on high-alert drug management. |
| The antimicrobial stewardship program includes interventions to optimize antimicrobial use: audit and feedback, formulary of targeted antimicrobials and approved indications, education, antimicrobial order forms, clinical guidelines and pathways for antimicrobial use, strategies for simplifying or reducing therapy, optimization of dosing, and parenteral-to-oral conversion of antimicrobials (if applicable). | Initial education on infusion pump use is provided at new nurse orientation, as well as at re-training. Training is provided and documented when user-controlled infusion pumps are issued to consumers. |
| Reports are generated on medication library adherence on infusion pumps. Results are available on the units and discussed at team meetings as needed. Good intercepts are accumulated annually and shared with staff for their feedback. Feedback from clients and families is also incorporated into improvements. Fact sheets are used to request a review of the medication library. Changes are discussed and implemented by the Intravenous Therapy Optimization Committee. |
In this context, how do you and your team provide services that are consistent with best practices for safe medication management? How do you report medication events and disseminate information necessary to mobilize and deploy appropriate medication safety practices?
We invite you to review the Required Organizational Practices (ROP) bulletins on medication safety management that are available on the CIUSSS’s intranet site. You can also participate in quizzes and draws.
Best practices
Several best practices have been implemented in our CIUSSS, including the following examples, which have had a significant impact on our users:
- Medication reconciliation is conduct with the user, family and caregivers to ensure that accurate and complete information is communicated. The Meilleur Schéma Thérapeutique Possible (MSTP) is generated, recorded and used to create admission orders or to provide a point of comparison with the current list of prescribed medication. The list is then shared with the consumer and their primary care practitioner, as needed.
A list of dangerous medications and abbreviations has been harmonized by the Medication Distribution Committee, and is available on the intranet (Politiques et procédures/1500 – Gestion sécuritaire du circuit du médicament). Pre-printed prescriptions are reviewed annually to ensure that dangerous abbreviations are not used.
At least two unique identifiers are used to confirm that the user is receiving the intervention or service intended for him/her, with the assistance of families. A policy and training modules are available on the intranet. To encourage the involvement of users, families and teams, a poster is placed at the points of care and services.
The transfer of information is secured by standardizing tools and documents, as well as by being recorded during admissions, transfers and discharges. Staff are familiar with the ways in which information is transferred to various partners in a timely manner. It is important for them to document these methods to effectively communicate information during the transition.
How do you and your team meet the standards for safe communication? How are you involved in improving safe communication with consumers, families and partners?
- CLICK HERE to read the required organizational practice (ROP) bulletins on safe communication. These documents are available on the CIUSSS’s intranet. You will also be able to participate in a quiz and a draw.
Virtual visits or activities
To adequately prepare, our CIUSSS's Telehealth team would like to invite staff who conduct virtual visits or any virtual activity to refer to the attached tool guide. It’s a one-page document designed to help remember the sequence of a virtual visit, set standards of practice among professionals, and harmonize staff responses when you are questioned by surveyors. Be sure to click on the underlined text to gain access to the supplementary resources.
