Bulletin #2 – Infection Prevention and Control

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Infection Prevention and Control (IP&C) theme focus is the first Quality and Safety theme of our series of nine themes between now and our onsite Accreditation survey October 22 – 25, 2018.

This theme focuses on reducing the risk of health care associated infections and their impact across the care continuum.  Specifically, it covers hand hygiene training and compliance, infection rates and guidelines, influenza and pneumonia vaccines and our processes for cleaning, disinfecting and sterilizing medical devices and equipment.

Within the IP&C there are four ROPs (Required Organizational Practices) that must be met to successfully complete Accreditation.

The 4 Infection Prevention and Control ROPs are:

  1. Hand hygiene education and training – Delivers hand hygiene education and training for staff, service providers, and volunteers. We also need to include residents/clients and visitors in our hand hygiene education.
  2. Hand hygiene audit – Evaluates compliance with accepted hand hygiene practices.
  3. Process for cleaning, disinfecting and sterilizing medical devices and equipment are monitored and improvements are made when needed.
  4. Infection rates – Health care-associated infection are tracked, information is analyzed to identify outbreaks and trends, and this information is shared throughout the organization.

Washing of hands with soap under running water.

Infection Prevention and Control Fact Sheet

At Menno Place we adhere to a number of organization wide policies, Ministry of Health and health authority guidelines that address infection prevention and control, including hand hygiene policies and practices, administration of influenza and pneumococcal vaccines, and processes for cleaning, disinfecting and sterilizing medical devices and equipment.

How will the Infection Prevention and Control ROPs be evaluated?

Surveyors will tour our Homes and will follow tests of compliance for each ROP. Specifically, surveyors will gather information by:

  • Reviewing resident health records
  • Reviewing employee files
  • Talking and listening to leaders, physicians, staff, students, volunteers, residents/tenants and visitors
  • Observing what takes place
  • Recording what they read, see and hear

Who needs to be aware of the Infection Prevention and Control ROPs?

Surveyors will meet randomly with staff, residents/tenants and visitors while they do their “tracers”. Everyone should be aware of all of the Quality and Safety themes and their associated ROPs and priority topics. If you are asked a question on an unfamiliar topic, please refer the surveyor to the appropriate individual or to your supervisor.

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 facility?
  • Do you know where the hand hygiene audit results are posted?
  • How easy was it for you to get your flu shot at work?
  • What would you do if you suspected a co-worker or resident/tenant had an infectious disease?
  • Do you have a system in place for cleaning and reprocessing resident care equipment such as tubs, suction machines, suture kits, etc.?

Who is on your Infection Prevention & Control Committee (IPCC)?

Kim C, (Chair), Leanne T, Angela R-F, Joanne S, Trish G, Lada K, Annette F, Brenda N.

Bulletin #1 – Accreditation Overview October 2018

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Accreditation 2018 Overview

Why Accreditation?

Menno Place has a legacy of caring, compassion and excellent services to our residents. Our last Accreditation occurred in 2013 in which Menno Home and Hospital attained Exemplary Status. We are now beginning preparations for our next survey in October 2018. This time Assisted Living will be part of our survey.

Through the Accreditation process, we have an opportunity to demonstrate our excellence in service delivery, identify opportunities for ongoing improvement, and continue to build on the successes and feedback from our last survey in October 2013.

Who is Accreditation Canada?

Accreditation Canada is a not-for-profit, independent organization that provides health care organizations across the country with an opportunity to assess their standards, systems, procedures and programs against international standards of excellence in order to provide our residents with the best possible service.

What is involved in the Accreditation Program?

Preparing our organization for the Accreditation Survey

We are in the process of preparing for our survey next year. This means that we will be communicating with all staff on a regular basis with regards to reviewing Accreditation standards and the opportunity to participate in a team that examines our system and processes to ensure we meet the standards. Our theme this year is “Bee” Prepared – our mascot is a Bee and we’ve created an Orange wall in each Home. The Orange wall will contain all kinds of information about Accreditation standards that everyone needs to understand and be familiar with. Please check the Orange wall on a regular basis.

Preparations are being made for a kick-off “Accreditation Fair” on October 25th. Please check the staff newsletter for up-dates on the Fair. Every month we will be sending out a “Bulletin” with information on a particular theme. You will find the “Bulletin” on the “Orange” wall, the staff newsletter and your manager will be sharing it at your unit/department meetings. Following the “Bulletin” releases we will be sending out Questions & Answers (Q&A) to help you prepare for the questions the surveyors may ask you.

 The Onsite Survey

The onsite Accreditation survey is scheduled to take place October 23 – 25, 2018. During the survey period, two peer surveyors from across Canada will visit our Campus. They will tour our Homes, review our processes, and speak to people. Specifically, they will gather information by:

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

The Accreditation survey is designed to assess our compliance with national standards for quality and safety of resident care. In particular, surveyors will be looking for the measures we have in place to meet the Required Organizational Practices (ROPs) set out by Accreditation Canada. There are 28 ROPs applicable to our Homes and we must demonstrate how we meet each of them to successfully complete Accreditation.

Quality & Safety Theme

There are eight themes that describe the ROPs and other priority topics related to Accreditation. The Quality & Safety Themes will be rolled out between now and September 2018 as follows:

  1. Infection Prevention and Control Theme (November & December)

Objective: Reduce the impact of health service acquired infections and their impact across the continuum of care/service with special focus on the provincial influenza immunization protocol and hand washing.

  1. Resident & Family Centred Care (December & January)

Objective: Create an organizational structure and culture that supports the implementation, spread, and success of a client- and family-centered care model

  1. Safety Culture Theme (February)

Objective: Create a culture of safety within our organization.

  1. Worklife Theme (March)

Objective:  Create a worklife and physical environment that supports the safe delivery of care/service.

  1. Emergency Planning Theme (April)

Objective: Prepare our organizations for disasters and emergencies.

  1. Risk Theme (May)

Objective: Identify safety risks inherent in our resident population.

  1. Communication Theme (June)

Objective: Improve the effectiveness and coordination of communication among care/service providers and among our residents, clients and their families.

  1. Ethics Theme (July)

Objective: Demonstrate our commitment to ensuring processes are in place to support resident safety efforts related to ethics, privacy and data management.

  1. Medication Use Theme (August)

Objective: Ensure the safe use of medications including medication reconciliation.

Your Participation

During the onsite visit, surveyors will speak to many people. You may be interviewed and observed so it is important that you understand our Quality & Safety Themes, the ROPs and other priority topics.

Thanks for your participation,

Hilde Wiebe, EDCS

Accreditation Coordinator