Bulletin #10 – Worklife – Workforce Theme

Worklife-Workforce is one of the Quality and Safety themes that we need to be aware of and knowledgeable about as we approach our Accreditation survey from October 22 – 25 2018. It focuses on creating a worklife and physical environment that supports the safe delivery of care/service. Within this theme, there are four Required Organizational Practices (ROPS) that Menno Place must meet to successfully complete Accreditation. A fifth standard under Worklife-Workforce does not apply to Menno Place. Additionally, there are other important Accreditation Standards that assist in ensuring staff are up-to-date in safety training.

The Worklife – Workforce ROPs are:

  1. Client Flow – Does not apply to Menno Place.
  1. Client Safety: Education and Training – Client safety training and education addresses specific client safety focus areas and are provided at least annually to leaders, team members and volunteers.
  1. Client Safety Plan – A client safety plan is developed and implemented at Menno Place.
  2. Preventative Maintenance – An effective preventative maintenance program for medical devices, medical equipment, and medical technology is implemented.
  3. Workplace Violence Prevention – Implements a comprehensive strategy to prevent workplace violence.

ROP 2    Client Safety: Education and Training

Surveyor Question: Tell me about the annual resident/client safety education you receive related to your work area.

Evidence:   We deliver client safety training and education at least annually to the leaders, staff, service providers and volunteers.

  • Policies and procedures are reviewed at each unit meeting
  • Staff sign that they are aware of the policies and where to access them
  • Staff sign commitment to safety
  • Emergency code/ fire drills
  • Hand Hygiene audits with immediate coaching
  • World Hand Hygiene Day Road Show

As part of our performance review process, all staff review safety policies and procedures such as fire safety, hand hygiene, emergency response plans, WHMIS, our Staff Safety Brochure, Immunization policy, and specific educational updates in their work areas such as safe Lifts and Transfers (No Lift policy) and prevention and management of aggression. We provide training at orientation and annually for a number of these topics. Our electronic system (SURGE) keeps a database which monitors which staff have taken courses and when. Staff can ask for a printout of the education they have taken. Nurses participate in a peer review system as part of their validation for licensure yearly.

ROP2     Client Safety Plan

                Surveyor Question:  Tell me about the Menno Place’s Safety Plan.


Our organization has developed Quality and Safety Plans that incorporate client safety measures and practices which are designed to address and evaluate safety issues. Some of the components of our plans are:

  • Safety Huddles (by staff teams and leaders)
  • Hand Hygiene audits and education
  • Trending of incidents and near misses and initiating improvement projects
  • Medication Reconciliation on admission and during transfers

We monitor and report a variety of indicators to the health authorities and share them cross-site. We look at such things as:

  • # of residents who have a fall
  • # of residents with a new fracture
  • # of residents with a facility acquired pressure ulcer
  • # of residents screen on admission for pain
  • # of medication errors requiring emergency intervention or treatment

Our Safety Plan includes provincial and national practices from the BC Patient Safety & Quality Council, Patient Care Quality Office, Provincial Licensing, Institute for Safe Medication Practices, Canadian Patient Safety Institute, Safer Healthcare Now and Accreditation Canada.

ROP3     Client Safety Roles and Responsibilities

Surveyor Question:  Can you please describe what roles and responsibilities staff and leaders have in resident/client safety? 


Everyone has a role in contributing to resident/client safety. All staff must be aware of all policies and procedures in the Sharepoint system or Administration Manual. All job descriptions include a role in safety. Our strategic plan has a goal to provide safe care/service.

Our organization is committed to a culture of safety, we have a number of safety policies which we teach our staff, students and volunteers including:

  • Health Care Consent
  • Immunization and Screening
  • Prevention and Management of Aggressive Behaviour
  • Incident Reporting and Tracking (Residents & General, Staff Injuries, Assisted Living) with Disclosure
  • Infection Control Program
  • Security
  • No Manual Lift
  • MSIP
  • Non/Least Restraint
  • Missing Resident
  • Smoke-Free Premises
  • Emergency Response
  • Workplace Inspections

ROP4     Preventative Maintenance Program

Surveyor Question: Is equipment regularly checked to ensure it is in good working order?

Evidence: Menno Place has a preventative maintenance system in place. Our maintenance (and rehabilitation) departments maintain lists of all medical and rehab equipment. Each piece has a serial number and a date for the next preventative maintenance inspection. The frequency and method of inspection depends on the equipment. We have an electronic system (Worxhub) and manual logs to track repairs and inspections.

ROP5     Workplace Violence Prevention

Surveyor Question: Please describe the strategy that Menno Place has in place to prevent workplace violence.

Evidence: We have a policy in place and provide training and education to staff.

Menno Place provides staff training throughout the year on Code White.  Staff who work with residents are expected to complete the 8 Violence Prevention modules provided through HEABC.  Menno Place has also had an HCA trained in the “Train the Trainer” program through SafeCare BC to present the 8 hour workshop on the Provincial Violence Prevention program.  There are 8 training sessions set up from March 2018 through February 2019 for staff to take part in.

Signage is located throughout Menno Place campus in the form of a red octagon with the words inside; “Violence, foul language, and abusive behaviours are not acceptable. Verbal threats or acts of violence will not be tolerated and may result in removal from this care home and/or prosecution.”  It is provided by SafeCare BC. Visitors are made aware that violence is not tolerated at Menno Place by reading the statement at each front door and signing in upon entry.

Menno Place has a bullying/harassment, code of conduct and respectful workplace policy that are introduced at orientation and reinforced with safety education.

Contractors go through a Contractor Safety Orientation prior to each job which notifies them of the Violence Prevention guidelines as well.