Congratulations! Accreditation 2022 Gets Exemplary Standing!
Menno Place achieves Exemplary Standing for our October 2022 Accreditation! Well done! Let’s celebrate at the July 27th Staff BBQ!
Menno Place achieves Exemplary Standing for our October 2022 Accreditation! Well done! Let’s celebrate at the July 27th Staff BBQ!
Surveyors will tour Menno Home & Menno Hospital and test compliance for over 200 standards including the Required Organization Practices (ROPs) listed below. They’ll be talking and listening to team members (like you!), families, residents, volunteers, and other partners. They’ll also be observing what is taking place as they tour the sites and reviewing resident health records.
Don’t forget to…
Will you BEE prepared if surveyors speak to you? Let’s review!
Within the safety quality dimension there are 4 ROPs that must be met to successfully complete Accreditation:
ROP 1: Accountability for Quality
ROP 2: Workplace Violence Prevention Program
ROP 3: Client Safety Incident Disclosure
ROP 4: Resident Safety Incident Management System
Click to Review Safety Culture
Within the resident safety quality dimension there is 1 ROP that must be met to successfully complete Accreditation:
ROP 1: Resident Safety Plan
Click to Review Resident Safety Plan
Infection Prevention and Control (IPC) covers hand hygiene education & training, compliance with accepted practices, and infection rate tracking and analyzing. Within the IPC there are 3 ROPs that must be met to successfully complete Accreditation:
ROP 1: HAND HYGIENE COMPLIANCE
ROP 2: HAND HYGIENE EDUCATION AND TRAINING
ROP 3: INFECTION RATES ARE TRACKED AND ANALYZED
Click to Review Infection Prevention & Control
Medication Management covers organizational safety practices related to medication management. Within Medication Management there are 5 ROPs that must be met to successfully complete Accreditation:
ROP 1: THE “DO NOT USE” LIST OF ABBREVIATIONS
ROP 2: HIGH ALERT MEDICATIONS
ROP 3: HEPARIN SAFETY AND MEDICATION CONCENTRATIONS
ROP 4: NARCOTICS SAFETY
ROP 5: MEDICATION RECONCILIATIONS ACROSS CARE TRANSITIONS
Click to Review Medication Management
Delivering Safe and Reliable Care is a subsection under Resident Care Experience as one of the Accreditation Themes. It focuses on ensuring our residents’ needs are met by providing safe and reliable individualized care. The Resident Care Experience theme includes 7 ROPs that must be met to successfully complete Accreditation. Here are the first 4:
ROP 1: Falls Prevention Strategy
ROP 2: Skin and Wound Care
ROP 3: Pressure Ulcer Prevention
ROP 4: Suicide Prevention
Click to Review Part 1: Delivering Safe & Reliable Care
Here are the remaining 3 ROPs:
ROP 5: Resident Identification
ROP 6: Information Transfer at Care Transitions (transfer in and out of care home)
ROP 7: Infusion Pump Safety
Click to Review Part 2: Delivering Safe & Reliable Care
Thank you for your support in making this Accreditation Survey another successful one!
Delivering Safe and Reliable Care is a subsection under Resident Care Experience as one of the Accreditation Themes. It focuses on ensuring our residents’ needs are met by providing safe and reliable individualized care. The Resident Care Experience theme includes 7 Required Organizational Practices (ROPs) that must be met to successfully complete Accreditation which will occur October 17 – 21, 2022. Here are the remaining 3 ROPs (part 2 of 2):
Surveyor Question: At Menno Place, how does the team confirm that residents receive the service or medication intended for them? How many resident identifiers are required?
Answer: In partnership with residents and families, there must be at least two person-specific identifiers used to confirm that resident receive the service or procedure intended for them (i.e. – medication administration).
Evidence: How do we do this?
Surveyor Question: How does the team ensure that information is transferred in an accurate and timely manner at transition points?
Answer: Information relevant to the care of the resident is communicated effectively during resident transfer in and out of care.
Evidence: How do we do this?
Not applicable to Menno Place
Thank you for your support in making this Accreditation Survey another successful one!
Delivering Safe and Reliable Care is a subsection under Resident Care Experience as one of the Accreditation Themes. It focuses on ensuring our residents’ needs are met by providing safe and reliable individualized care. The Resident Care Experience theme includes 7 Required Organizational Practices (ROPs) that must be met to successfully complete Accreditation which will occur October 17 – 21, 2022. Here are the first 4 ROPs:
Surveyor Question: Tell me about what the Fall Prevention Strategy is for your residents.
Answer: To minimize injury from falls, a documented and coordinated approach for falls prevention is implemented and evaluated. .
Evidence: How do we do this?
Surveyor Question: Tell me what processes are in place for skin and wound care.
Answer: An interdisciplinary and collaborative approach is used to assess residents who need skin and wound care and provide evidence-informed care that promotes healing.
Evidence: How do we do this?
Surveyor Question: Tell me what processes are in place to prevent pressure ulcers.
Answer: Risk for developing a pressure ulcer is assessed and interventions to prevent pressure ulcers are implemented.
Evidence: How do we do this?
Surveyor Question: How does your organization identify and document suicide risk among residents?
Answer: Residents are assessed and monitored for risk of suicide.
Evidence: How do we do this?
Stay tuned:
Thank you for your support in making this Accreditation Survey another successful one!
Medication Management is one of our Accreditation Themes. It covers organizational safety practices related to medication management. Within Medication Management there are 5 Required Organizational Practices (ROPs) that must be met to successfully complete Accreditation which will occur October 17 – 21, 2022.
Surveyor Question: At Menno Place, do you ensure that incorrect abbreviations and symbols that may cause errors are not used on any written, printed or electronic materials?
Answer: Yes, we follow the Institute for Safe Medication Practices (ISMP) list of error-prone abbreviations, symbols, and dose designation which is reviewed regularly by our Medical & Medication Safety and Advisory Committee (MMSAC).
Evidence: How do we do this?
Surveyor Question: At Menno Place, do you have a comprehensive strategy for managing high-alert medications?
Answer: Yes, we follow the process of our policy RCS 6.13 High-Alert Medications.
Evidence: How do we do this?
Surveyor Question: How does Menno Place ensure that heparin products are limited and stored safely?
Answer: Heparin is identified as high alert medication. We limit the use of heparin products and order only the low molecular weight heparin under specific circumstances.
Evidence: How do we do this?
Surveyor Question: How does your team ensure that narcotics are stored and used safely?
Answer: Narcotics are identified as high alert medication. We limit narcotics, ensure restricted access, and educate staff on their usage reduces medication errors.
Evidence: How do we do this?
Surveyor Question: What process is in place to ensure that the best possible medication history is obtained and that the resident gets the right medication orders?
Answer: Medication reconciliation is conducted in partnership with the resident, family, caregiver, and pharmacy to communicate accurate and complete information about medications across transitions of care.
Evidence: How do we do this?
Thank you for your support in making this Accreditation Survey another successful one!
Infection Prevention and Control (IPC) covers hand hygiene education & training, compliance with accepted practices, and infection rate tracking and analyzing. Within the IPC there are 3 Required Organizational Practices (ROPs) that must be met to successfully complete Accreditation which will occur October 17 – 21, 2022.
Who is on your Infection Prevention & Control Committee (IPCC)?
Kim Scott (Chair), Smitha Varghese, Anitha T, Leanne T, Angela R-F, Linda W, Trish G, Moreen R, Annette F, FHA IPC representative.
How will the ROPs be evaluated?
Surveyors will tour Menno Home & Menno Hospital and test compliance for each of the ROPs. Specifically they will gather information by:
Who needs to be aware of the Infection Prevention and Control ROPs?
Surveyors will meet with team members, residents, families, students and volunteers so everyone should be aware of this IPC theme and the associated ROPs and priority practices. If you are asked a question on an unfamiliar topic, please refer the surveyor to the appropriate individual or supervisor.
Surveyor Question: How do we evaluate compliance with accepted hand hygiene practices?
Answer: We evaluate hand hygiene compliance by directly observing (audit) the practice using the Speedy Audit tool.
Evidence: How do we do this?
Surveyor Question: What education and training have you received on hand hygiene?
Answer: We receive regular education assigned to us in Surge Learning, we have visual signs posted throughout our site, we receive hands on education at unit team meetings, and direct feedback by hand hygiene peer auditors.
Evidence: How do we do this?
Surveyor Question: How do we track infection information, analyze it, and communicate this information throughout the organization?
Answer: We track infection rates, analyze the information to identify clusters, outbreaks and trends; this is shared throughout the organization.
Evidence: How do we do this?
Thank you for your support in making this Accreditation Survey another successful one!
Resident safety is one of the Accreditation Required Organizational Practices (ROP’s) that must be met to successfully complete Accreditation which will occur October 17-20, 2022. Menno Place has a Resident Safety Plan to ensure our delivery of care and services are provided safely to the residents and for the team members. Here is the summary information of our Menno Place Resident Safety Plan. The full plan can be found on SharePoint.
Click for SharePoint login page | Click for instructions to login to SharePoint
Surveyor Question: Does Menno Place have a developed and implemented Resident Safety Plan?
Answer: Yes, Menno Place has a Resident Safety Plan that assesses and addresses resident safety.
Evidence: How do we do this?
The Resident Safety Plan supports Menno Place’s mission and vision by providing the mechanisms to improve resident safety and reduce identified risks. This is accomplished through the collection and analysis of data from various direct care and support functions of the care home within Menno Place.
A number of indicators are reported to Fraser Health including:
Internal monitoring of resident safety measures and practices designed to address and evaluate safety matters include, but are not limited to:
Proactive Approaches:
Safety is one of our Accreditation Quality Dimension. It focuses on creating a culture of safety at Menno Place. Within the safety quality dimension there are 4 Required Organizational Practices (ROPs) that must be met to successfully complete Accreditation which will occur October 17-20, 2022.
How do we comply with the Safety ROPs?
Menno Place has dedicated resources to adopt and implement a variety of safety reporting measures including reporting events and disclosing them. Safety is embedded in Menno Place’s Strategic Plan. Leaders regularly report to the Quality Improvement Risk Management Committee (QIRM) on safety concerns and provide recommendations and progress reports on key initiatives in process. Additionally, leaders provide detailed review on all the quality indicators.
How will the ROPs be evaluated?
Surveyors will tour Menno Home & Menno Hospital and test compliance for each of the ROPs. Specifically they will gather information by:
Who needs to be aware of the Safety Culture ROPs?
Surveyors will meet with teams, physicians, staff, residents, families, students and volunteers so everyone should be aware of the Safety Quality Dimension and the associated ROPs and priority practices. If you are asked a question on an unfamiliar topic, please refer the surveyor to the appropriate individual or supervisor.
Surveyor Question: Does the Menno Place Board have a demonstrated commitment to quality performance in the organization.
Answer: Yes, the Board of Menno Place demonstrates a clear commitment to quality by having it as a standing item on the agenda of its meetings.
Evidence: How do we do this?
Surveyor Question: Does Menno Place have a documented and coordinated approach to prevent workplace violence?
Answer: Yes, Menno Place does have a documented and coordinated approach to prevent workplace violence.
Evidence: How do we do this?
Surveyor Question: Does Menno Place have a documented and coordinated approach for disclosing client safety incidents to residents and families?
Answer: Yes, Menno Place has a policy “Disclosure of Harm or Near Miss” AP 2.28, available on SharePoint.
Evidence: How do we do this?
Surveyor Question: Are there processes in place to review client safety incidents, recommend actions and monitor improvements?
Answer: Yes, Menno Place addresses client safety incidents and takes action to reduce any risk of recurrence.
Evidence: How do we do this?
What are some of the questions surveyors may ask about Safety Culture?
During the onsite visit, surveyors will ask questions about Menno Place and how they comply with the ROPs and standards. A sample of questions may include the following:
Thank you for your part in making this Accreditation Survey another successful one!
We want to BEE the best! Being accredited allows Menno Place to be measured against world class evidenced based health care standards. The goal is to provide the best healthcare and services to our residents so we can do what we do best: care for and improve lives.
Save the Date: Oct 17th to Oct 21st, 2022
These are the dates the Accreditation surveyors will be on site. Preparation is already underway and will continue until then. Stay connected by attending your team huddles, reading the https://mennoplacestaff.com/ updates, and participating in the fun events to come.
Onsite at Menno Home and Menno Hospital in all areas of care, services, and support.
Will you BEE prepared?
Accreditation Canada (AC) is an independent, non-government, not-for-profit organization affiliated with Health Standards Organization (HSO), located in Ottawa, Ontario. AC is committed to inspiring people to make positive change that improves the quality of health and social services in Canada and around the world. HSO develops world-class and evidence-based standards, assessment programs, and quality improvement solutions. AC and HSO use a People-centered care philosophy and approach to setting its standards and guiding the accreditation process.
The Accreditation Tool is organized into six chapters:
Chapter 1: Governance and Leadership
Addresses criteria assessed by governing bodies and/or leadership teams and defines the standards under which the organization or LTC home’s management operates.
Chapter 2: Delivery of Care Models
Addresses thematic areas related to team management, talent development, work-life, information management, quality improvement and delivery of virtual health services.
Chapter 3: Emergency Disaster Management
Addresses emergency, disaster, and outbreak management, focusing on reducing risk and being prepared to respond to and recover from an emergency, disaster or outbreak that occurs inside or outside of the organization.
Chapter 4: Infection Prevention and Control
Addresses organizational infection prevention and control (IPC) practices that promote a collaborative approach in providing safe and reliable services and preventing transmission of pathogens and health care-associated infections.
Chapter 5: Medication Management
Addresses organizational medication management practices that promote a collaborative approach in providing safe and reliable services.
Chapter 6: Residents’ Care Experience
Focuses on ensuring the needs of LTC home residents are met by providing safe and quality individualized care from competent teams.
These chapters are further broken down into eight quality dimensions that all play a part in providing safe, high-quality care.
Watch for these themes to come in future bulletins.
USE OF MATERIALS
All materials available on the www.MennoPlaceStaff.com website are published for the sole purpose of keeping informed those individuals who work on the Menno Place campus. These materials may be shared with others who are also connected to the Menno Place campus in this same way. No content or material may be used or shared in any other context without the written permission of the Menno Place Director who oversees communications.