Outstanding score for CIUSSS in Accreditation Canada visit
Healthcare network commended for attention to safety, access and person-centred care
CIUSSS West-Central Montreal has earned a nearly perfect score in a preliminary report from Accreditation Canada, whose representatives commended the healthcare network for the quality of its person-centred care and for the involvement of all sites and departments in ensuring the safety of users and staff.
An official report is expected from Accreditation Canada in early 2019. However, the initial results—presented by the team leader, Marie-Suzanne Lavallée, on November 28 in a video hookup with many of the network’s facilities—prompted Dr. Lawrence Rosenberg, President and CEO of the CIUSSS, to praise staff for their “diligence, persistence, passion and deep commitment,” and to thank them for what he called “an EXCELLENT score.”
“You all performed brilliantly,” Dr. Rosenberg continued in his message. “I am awed and privileged to be working with such a gifted group of professionals. You should all take pride in our accomplishment.”
The inspection, more commonly known as a “visit”, was carried out from November 25 to 28. While a broad range of the CIUSSS’s missions and facilities were surveyed, particular attention was paid to the Jewish General Hospital, Richardson Hospital, Henri Bradet Residential Centre, MAB Mackay Rehabilitation Centre, CLSC Park Extension, the Goldman Herzl Family Practice Centre and Donald Berman Jewish Eldercare Centre.
This was the first in a series of annual visits in a five-year cycle, with each visit emphasizing different aspects of the CIUSSS’s practices and services. Surprise visits may also be conducted at any time in later parts of the cycle.
The overall score of 99.6 per cent represents the CIUSSS’s nearly flawless performance in 13 priority processes, 18 required organizational practices and 566 specific criteria. Perfect scores were registered in the broad areas of medication management, governance, and the reprocessing of reusable medical equipment, plus very high marks for infection prevention and control, and leadership.
All 18 of the required organizational practices were fulfilled, including:
- Prevention of infection, which is kept to minimal levels
- Development of a patient safety plan
- The process of reporting adverse incidents
- Security procedures in the use of narcotics and heparin
- Implementation of a program to prevent workplace violence
The visitors also overwhelmingly approved of the CIUSSS’s performance in eight facets of the quality of care:
- Delivering user-centred care, with involvement by the user and his/her family
- Providing fair and timely access to care
- Offering treatment and care that are intended to achieve the best results
- Providing continuity and coordination throughout the entire trajectory of care
- Foreseeing and meeting society’s needs
- Ensuring the safety of users and personnel
- Providing a good workplace environment
- Optimizing the use of resources
“What we have achieved is clearly a result of attention to detail on a daily basis by all members of staff,” says Anne Lemay, Associate Executive Director for the Support, Administration and Performance Programs. “We are participating in an ongoing project of great significance, whose ultimate goal makes sense for everybody.
“This what Accreditation Canada saw in us, as we pursue our vision of providing an exceptional user experience. It is also reflected in the recent survey of staff, in which our employees expressed their pride in the quality of the services that we provide.”
“This visit confirms the engagement of everyone on staff and their dedication to the continuous improvement of quality,” says Chantal Bellerose, who is Associate to Ms. Lemay and is Director of Quality, Evaluation, Performance, Ethics and Archives.
Ms. Bellerose, who is also Coordinator of Quality, Risk Management, Accreditation, Clinical Ethics and the User Experience, adds that the visitors from Accreditation Canada “recognized the balance that we have achieved between standardizing our practices and maintaining enough flexibility to meet the needs of all healthcare users.”
Among the successes that were singled out during the presentation of the preliminary results:
- The CIUSSS’s highly engaged users’ committee, plus the involvement of patient partners in ensuring person-centred care (a high priority for accreditation)
- Transparency in risk management, with involvement by all departments in ensuring the safety of users and staff, plus the systematic implementation of a risk management program (a high priority)
- The presence of an integrated strategic plan that includes quality indicators, supported by a culture of measuring performance (a high priority)
- Physicians and staff who are engaged and enthusiastic
- A dynamic board of directors and strong medical leadership
- A high level of safety in medication management
- Excellent budgetary control
- Excellent tools of communication to convey high-quality information
- A safe, healthy environment for users, and a superior level of cleanliness in the sterilization of reusable equipment
- A culture of infection prevention and control that is integrated into all healthcare teams and services, with an approach that is customized to each site in the network
- The presence of a global plan to deal with potentially dangerous situations, with simulation exercises and training for staff
Also identified were near- and long-term challenges with which the CIUSSS will have to grapple. These include budgetary limitations, as well the need to continue building on successes such as:
- Developing a culture of innovation that involves all members of staff
- Coping with the effects of an aging workforce
- Reminding staff about practicing proper hand hygiene before coming into contact with patients
- Keeping documentation about emergency measures up to date
- Communicating effectively with numerous partners in many facilities across the CIUSSS
“The synergy that we have achieved among leaders, managers, healthcare staff, administrative employees, patient partners, volunteers and community partners is priceless and has been essential in our recipe for success,” says Ms. Bellerose. “I’m proud to have offered my support during accreditation and I look forward to our ongoing transformation.”