Accreditation Starts Oct 17!

/in , ,

Accreditation 2022 Starts Monday, Oct 17!

Accreditation surveyors will be on site at Menno Home and Menno Hospital in all areas of care, services, and support from Oct 17 – 21.

Thank you for your hard work in preparing for this Accreditation Survey.
Let’s make it another successful one!

Click here to Review All ROPs

Accreditation Oct 17-21, 2022: Do you know your stuff?

/in , ,

Accreditation is just around the corner on October 17 – 21, 2022!

What does that mean for you?

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…

  • Showcase the great work of your team. How are you continuously striving to create meaningful and purposeful experiences with residents and families while providing safe, quality care? Prepare some examples.

Will you BEE prepared if surveyors speak to you? Let’s review!

Safety Culture

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

Resident Safety

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 & Control

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

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

Resident Care Experience
Part 1: Delivering Safe & Reliable Care

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

Resident Care Experience
Part 2: 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!

Accreditation Bulletin #7 – Resident Care Experience Part 2

/in , ,

BULLETIN #7 – Resident Care Experience

Part 2: Delivering Safe & Reliable Care

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):

ROP #5: Resident Identification

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?

  • Menno Place has a Resident Identification policy RCS 2.09
  • Staff are required to verify residents by 2 identifiers before providing any service or care to a resident, often with the involvement of the resident or family.
  • Menno Home/Hospital uses the following identifiers:
    1. Photographs of residents found in Point Click Care profiles, eMAR (Home) & medication boxes (Hospital), Point of Care, Resident room doors (Home), and inside room (Hospital), etc.
    2. Consult with another team member who is aware of the resident’s identification
    3. Chart labels/profile includes name, PHN, birthdate, etc. is used in conjunction with above two.

ROP #6: Information Transfer at Care Transitions (transfer in and out of care home)

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?

  • Internal transfer: ensure timely and accurate transfers between units include a combination of verbal and written information. Examples include: the electronic health record, the paper health record, verbal report nurse to nurse.
  • Shift change/breaks: verbal and written reports are used for shift changes and breaks. Written reports include electronic documentation and shift summary forms.
  • External transfer: several practices to ensure accurate and timely transfer of information includes faxing, sending completed transfer sheets, telephone calls or giving verbal information face to face, including standard transfer sheet located in resident records and standardized physician discharge summaries.
  • Care conference: collaborate and interdisciplinary meetings with electronic records to verify and plan actions and goals of care and quality of life with resident, family/ caregiver, and team members.

ROP #7: Infusion Pump Safety

Not applicable to Menno Place

Thank you for your support in making this Accreditation Survey another successful one!

Accreditation Bulletin #6 – Resident Care Experience

/in , ,

BULLETIN #6 – Resident Care Experience

Part 1: Delivering Safe & Reliable Care

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:

ROP #1: Falls Prevention Strategy

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?

  • Our organization has a policy on Falls Assessment and Prevention RCS 2.02. All nursing staff are aware of the policy and follow its procedures. Our Falls Prevention policy is based on Fraser Health’s Clinical Practice Guidelines (CPG).
  • Screening all residents upon move-in to determine their nature of risk for falls and related injuries and completing a fall risk assessment in Point Click Care (PCC).
  • Initiating a care plan which is then implemented, monitored, and evaluated regularly. Communicated with resident and family members.
  • Educating residents, caregivers, team members, and volunteers about fall prevention.
  • Evaluating the effectiveness of the fall assessment & prevention programs by discussing incidents, causes, trends, and interventions for prevention and make improvements.
  • Involving Occupational and Physio Therapists to recommend equipment, assistive aides, and walking programs.
  • Ongoing assessment and evaluation of incident reports as appropriate

ROP #2: Skin and Wound Care

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?

  • Menno Place has a wound care policy RCS 2.54 which is based on clinical practice guidelines provided by Fraser Health.
  • Each resident is assessed at move-in using the Braden Scale to measure their status and determine treatment. The lower the scores, the greater the risk.
  • Regular assessments are conducted and specifications about what dressings or treatments are appropriate for the specific condition using a collaborative approach with physician, nurse, and wound care specialists.
  • If assessments deem that skin condition is worsened or new risks identified, the care plans are updated and communicated to team members, families, and caregivers.
  • Referrals are made to wound care clinicians, the dietitian, and the OT to ensure everything is done to promote wound healing and appropriate treatment.
  • Regular education is provided to team members and to family members/caregivers.

ROP #3: Pressure Ulcer Prevention

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?

  • Menno Place has a wound care policy RCS 2.54 which is based on clinical practice guidelines provided by Fraser Health to prevent and treat pressure ulcers.
  • All residents are screened on admission and at regular intervals including changes in status using the Braden Scale to determine Pressure Ulcer Risk.
  • Care plans are developed to assist residents in preventing and managing pressure ulcers using specific interventions for them.
  • Development of pressure ulcers including interventions to:
    • Prevent skin breakdown
    • Minimize pressure, shear and friction
    • Reposition
    • Manage moisture
    • Optimize nutrition and hydration
    • Enhance mobility and activity
  • Occurrence of pressure ulcers are reported, tracked, and monitored by the organization and reported to Fraser Health.
  • Staff, residents, and family members receive education about risk factors and strategies used to prevent pressure ulcers.
  • Strategies for measuring the effectiveness of pressure ulcer prevention are monitored and improved as indicated.

ROP #4: Suicide Prevention

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?

  • Our organization has a policy on Resident Risk of Suicide RCS 2.53 which is based on clinical practice guidelines provided by Fraser Health.
  • Residents are identified at risk of suicide through the move-in day interview tool and at regular intervals.
  • Immediate safety measures are implemented if a resident is identified at risk of suicide, including social workers completing suicidal risk assessment with 15-minute checks if resident voices suicidal ideations.
  • Social workers, team members, resident, and family member/caregiver strategize on interventions to treat and monitor a resident at risk of suicide.
  • Implementation of the treatment and monitoring strategies are recorded in the resident record.

 

Stay tuned:

  • Part 2 on Delivering Safe & Reliable Care will be coming out soon.

 

Thank you for your support in making this Accreditation Survey another successful one!

Accreditation Bulletin #5 – Medication Management

/in , ,

BULLETIN #5 – Medication Management

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.

ROP #1: THE “DO NOT USE” LIST OF ABBREVIATIONS

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?

  • “Do Not Use” list is on each unit and easily available
  • Every item on the “Do Not Use” list is removed from all written, printed, and electronic documents.
  • Nurses and physicians are made aware of the list and the policy RCS 6.02 Medication Administration System.
  • Preprinted orders are reviewed annually by the MMSAC and are free of ‘Do Not Use’ abbreviations.
  • Audits are completed regularly to ensure compliance with the “Do Not Use” lists.

ROP #2: HIGH ALERT MEDICATIONS

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?

  • Follow policy RCS 6.13 High-Alert Medications
  • Follow the Institute for Safe Medication Practices (ISMP) list of high-alert medication
  • Educate and train nurses on high-alert medication management
  • Audit the process of double check verification done by nurses
  • The policy is reviewed annually by the MSACC

ROP #3: HEPARIN SAFETY AND MEDICATION CONCENTRATIONS

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?

  • Follow policy RCS 6.13 High-Alert Medications
  • We do not store high dose heparin products onsite
  • High-alert medications are stored in a locked medication cart in locked medication rooms.

ROP #4: NARCOTICS SAFETY

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?

  • Follow policy RCS 6.13 High-Alert Medications
  • Follow policy RCS 6.10 Narcotics & Narcotic Record
  • All narcotics are either stored in a locked narcotic cupboard or locked medication carts
  • Two nurses are required to count narcotics every 24 hours
  • A nurse must always be responsible for the keys to the narcotics cupboard and medication room.

ROP #5: MEDICATION RECONCILIATIONS ACROSS CARE TRANSITIONS

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?

  • Follow policy RCS 6.08 Medication Reconciliation
  • All new resident move-ins, transfers back into the care home from acute care or move-outs have medication orders reconciled to ensure accuracy and continuity of medications.
  • Nurses complete the medication reconciliation form for each care transition which gets verified by the physician.
  • New nursing team members are trained at orientation before their first shift worked.

 

Thank you for your support in making this Accreditation Survey another successful one!

Accreditation Bulletin #4 – Infection Prevention and Control

/in , ,

BULLETIN #4 – Infection Prevention & Control

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:

  • Talking and listening to team members, families, residents, volunteers, and community partners such as physicians, pharmacists, and contractors.
  • Observations of what is taking place as they tour the sites
  • Reviewing resident health records and/or Employee files

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.

ROP #1: HAND HYGIENE COMPLIANCE

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?

  • We have a policy (AP 5.05 Infection Prevention & Control Program)
  • We have trained Hand Hygiene auditors who regularly conduct peer audits.
  • Audits are reviewed with the Infection Prevention and Control Committee, sent to leaders, and then shared with team members at unit team meetings and department meetings
  • Audits are posted on our bulletin boards and visible to residents, families, visitors, and volunteers.
  • Concerns and trends are followed up on
  • Our audits provide valuable information to our leaders and staff in developing and implementing strategies to improve hand hygiene. For example, based on feedback, we have installed more hand sanitizers in targeted areas.

ROP #2: HAND HYGIENE EDUCATION AND TRAINING

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?

  • Annual Hand hygiene education for all staff and volunteers
  • Hand hygiene education at orientation and on Surge Learning (ongoing)
  • Annual COR certification
  • Hand hygiene is discussed with all families during move-in
  • Posters throughout the building
  • Hand hygiene is discussed at family councils and resident councils
  • Education – Fact sheet – posted in Newsletter

ROP #3: INFECTION RATES ARE TRACKED AND ANALYZED

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?

  • We track infections by completing the infection log monthly
  • Complete infection surveillance sheets for all infections
  • We have an Infection Prevention and Control Committee where we analyze monthly data
  • All outbreaks are reported to our Infection Control Lead (Kim Scott), who follows up according to the infection control manual’s outbreak management guidelines from FHA
  • Outbreaks are managed in partnership with health authority medical health officers.
  • Infection rates are displayed on a report sheet every month; the graph is shared with team members at unit/department meetings.
  • Outbreak information is shared at monthly Leadership team meetings and quarterly at the Quality Improvement Risk Management Board committee (QIRM).
  • We have a Policy:  APS 5.05 – Infection Prevention and Control Program

 

What are some sample questions that surveyors may ask about the Infection Prevention and Control theme?

  • How do you get regular information about infection control issues?
  • Do you know about the infection rates within your care home?
  • Do you know where the hand hygiene audit results are posted?
  • How easy was it for you to get your flu/covid vaccination at work?
  • What would you do if you suspected a co-worker or resident had an infectious disease?

Thank you for your support in making this Accreditation Survey another successful one!

Accreditation Bulletin #3 – Resident Safety

/in , ,

BULLETIN #3 – RESIDENT SAFETY

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 

ROP: Resident Safety Plan

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:

  • % of residents with worsened behaviours
  • % of residents with urinary tract infections
  • % of residents with stage 2-4 pressure ulcers
  • % of residents with pain
  • % of residents with unscheduled transfers to emergency
  • % of residents with restraints
  • % of residents that have fallen
  • % of residents with antipsychotics without a diagnosis
  • % of residents prescribed more than 9 medications

Internal monitoring of resident safety measures and practices designed to address and evaluate safety matters include, but are not limited to:

  • Ongoing education, training, and communication, including hand hygiene audits
  • Tending of incidents and near misses, and initiating improvement projects
  • Medication reconciliation at move-in and during transfers
  • Incident Reports
  • Resident/Family concerns/complaints
  • Employer incident investigation report
  • Pharmacy input and interventions
  • Licensing agency complaints/investigation
  • Resident healthcare record reviews
  • Workplace safety audit
  • Heat Preparedness Plan

Proactive Approaches:

  • Ethics Committee
  • Staff/Resident/Family Input
  • Unit level huddles/rounds/meetings
    • Environmental
    • Clinical
    • Infection Control
  • Community Care Licensing Information and Reports
  • Partnerships with external sources such as Fraser Health, BC Patient Safety & Quality Council, and Worksafe BC.

Accreditation Bulletin #2 – Safety Theme

/in , ,

BULLETIN #2 – ACCREDITATION – SAFETY BULLETIN

SAFETY CULTURE

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:

  • Talking and listening to team members, families, residents, volunteers, and community partners such as physicians, pharmacists, and contractors.
  • Observations of what is taking place as they tour the sites
  • Reviewing resident health records

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.

ROP 1  Accountability for Quality

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?

  • The Board is engaged in overseeing quality in order to ensure that quality performance continually improves. Governing bodies are accountable for the quality of care provided by their organizations. The Board is aware of key quality and safety principles in order to understand, monitor, and oversee the quality performance of the organization.
  • The Board has a clear commitment to quality as evidenced by having it as a standing item at each meeting.
  • The Leaders and Board review a number of indicators on a regular basis.
  • Resident safety is embedded in the Menno Place strategic plan.
  • Menno Place’s quality performance indicators are directly linked to strategic goals and objectives. Knowledge gained from the review of quality performance indicators (i.e. data collected on number of falls, pressure ulcers, restraints, sick time, injuries etc.) is used to set the agenda, inform strategic planning, and develop an integrated quality improvement plan. Resource allocation may be determined by priorities arising out of evaluation of quality performance.
  • Menno Place has a Quality Improvement and Risk Management Committee (QIRM). This committee consists of Senior Leaders and Directors and Board members and meets quarterly. The QIRM committee reports to the Board.

ROP 2 Workplace Violence Prevention Program

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?

  • We have written policies, available on SharePoint: Workplace Violence Prevention AP 3.41 and Workplace Harassment and/or Bullying AP 3.43
  • Risk assessments are conducted to determine and identify the risk of workplace violence
  • Staff are educated and trained on workplace violence prevention through Surge learning and hands on workshops.
  • The JOHS committee regularly reviews policies, incidents, and conducts audits and assessments to prevent workplace violence.

ROP 3 Client Safety Incident Disclosure

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?

  • Disclosure is the process used by Menno Place to inform a resident and/or their family of a specific harmful incident. During this process the implications of that incident are discussed in a respectful, sensitive, and thorough manner. Part of the process involves support for residents and staff as well.
  • Menno is committed to honest and open communication with residents and families when harm occurs. This may include a fall with injury, medication error, unexpected death, missing resident, theft, etc.
  • A complete, accurate, and factual account of the disclosure discussion(s) is recorded in the resident’s health record.
  • An example of support to resident’s, families, and team members includes emotional/psychological support by social worker, 3rd party counseling service such as the Employee Family Assistance Program, and/or spiritual care.

ROP 4 Resident Safety Incident Management System

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?

  • Menno Place encourages everyone to report and learn from resident safety incidents including harmful, no-harm and near miss. The reporting system is simple, clear, confidential, and focused on system improvement.  Residents and families are also encouraged to report.
  • We have written policies, available on SharePoint: Incident Reports RCS 1.09, Reportable Incidents RCS 1.14, and Safety of Residents RCS 2.01.
  • We utilize resources from the Canadian Patient Safety Institute and learns from shared client safety incidents from other sources.
  • Broadly communicating incident analysis internally and externally in order to build confidence in incident management and promote collective learning.

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:

  • Do staff feel there is a no blame culture?
  • Are there open discussions about resident safety issues in each neighborhood?
  • What can you tell us about the incident reporting system at Menno Place?
  • Can you tell me about an improvement initiatives that has occurred in your work area over the past year?
  • Have you reported any near miss incident? Can you give an example?
  • Can you define a harmful event?

Thank you for your part in making this Accreditation Survey another successful one!

Bulletin #15 – Medication Use Theme

/in , , ,

MEDICATION USE: Ensure the safe use of high‐risk medications.

The Medication Use ROPs are:

  1. Concentrated electrolytes – Not applicable for Menno Home/Hospital.
  2. Heparin safety – The availability of heparin products is evaluated and limited to ensure that formats with the potential to cause patient safety incidents are not stocked in client service areas.
  3. High‐alert medications – A documented and coordinated approach to safely manage high‐alert medications is implemented.
  4. Narcotic safety – The availability of narcotic products is evaluated and limited to ensure that formats with the potential to cause patient safety incidents are not stocked in client service areas.

Surveyor Question: At Menno Place, how does the organization ensure that abbreviations, symbols, and dose designations are not used on any written, printed or electronic materials?

Evidence:

  • “Do Not Use” Abbreviation List is on each unit and easily available.
  • Every item on the “Do Not Use” Abbreviation List is no longer on any written, printed, or electronic document.
  • Staff and physicians are made aware of the “Do Not Use” Abbreviation List and the policy.
  • Preprinted orders are reviewed annually and are free of “Do Not Use” abbreviations. There are no “Do Not Use” Abbreviations present on any written, printed or electronic documents.
  • Audits are completed regularly to ensure the “Do Not Use” Abbreviations are not used.

Heparin Safety and Medication Concentrations

Heparin is identified as a high alert medication that is an area of focus for safety.

Surveyor Question: How does your organization ensure that heparin concentrations are standardized and limited?

Evidence:

  • Our organization uses manufactured products in pre-filled pharmacy unit doses.
  • We do not store high-dose heparin products.
  • Audits are completed annually, to ensure no high-dose heparin products are present on the units.

 Narcotic Safety

Narcotics are identified as high alert medications for safety reasons. Limiting different doses of narcotics, ensuring restricted access, as well as educating staff on their use reduces medication errors.

Surveyor Question: How does your team ensure that narcotics are stored and used safely?

Evidence:

  • All narcotics are stored in a locked narcotic cupboard.
  • Two nurses are required to count narcotics.
  • A nurse is responsible for the keys to the narcotics cupboard.
  • The Medical Medication Safety Advisory Committee (MMSAC) reviews medications stocked in contingency, ensuring no high dose narcotics are on-site.
  • Audits are completed ensuring high dose narcotics are not stocked in med rooms.

Bulletin #14 – Ethics Theme

/in , ,

Menno Place is committed to fostering an ethical environment that supports ethical practices, decision-making and reflection.  Issues brought forward at Menno Place are discussed utilizing a framework (algorithm) for making ethical decisions. It helps guide our ethical decision-making practice within our organization.

The Menno Place Ethics Committee meets regularly to review ethical issues brought forward by staff. During the meetings, articles pertaining to current or potential issues are discussed.  The Ethics Committee at Menno Place acts as a resource to staff, residents and family members through the provision of education, training and working through ethical issues.

The following tools exist at Menno Place as tools for working through ethical issues, making referrals, guiding decisions and providing timelines for education.

  1. AP 1.08 (Index) – Annual Goals & Objectives
  2. AP 1.09 (Index) – Committee Structure
  3. AP 5.06 (Index) – Ethical Decision Making Process; Process Map & SBAR
  4. AP 1.01 (Index) – MBS – Vision/Mission/Values
  5. AP 2.12 (Index) – Continuing Education for Managers and Employees
  6. AP 2.02 (Index) – Research
  7. Terms of Reference for Ethics Committee
  8. Ethics Committee Referral Form

How does Menno Place deal with research opportunities?

When Menno Place is approached for research opportunities, there is a policy outlining the requirements for the researcher that must be followed. All submissions are reviewed by the Board.

How are leaders, staff, physicians, residents and families supported in the ethics decision-making process?

Ethical decision-making is an integral part of daily practice. Leaders, staff and physicians are encouraged to raise ethical issues within their area and discuss them with their leader or supervisor, as they feel comfortable. In most situations, clinical ethics are handled by the individuals and team(s) involved. However, a referral to the Menno Place Ethics Committee is made when the team requires additional support.

Who can ask for an ethics consult?

Anyone can request an ethics consult – residents, families, staff, physicians, leaders and administrators.

How will our ethics standards and processes be evaluated during the Accreditation Survey?

Surveyors will tour our sites and will follow a test(s) of compliance. They will gather information by:

  • Reviewing resident health records and documentation
  • Talking and listening to leaders, physicians, staff, students, volunteers, residents and families
  • Observing what takes place
  • Recording what they read, see and hear

Who needs to be aware of our ethics standards and practices?

Everyone! If you have any questions please ask your supervisor.