Making the grade!
- September 2002
Receiving a Three Year Accreditation Award with Report from the national Canadian Council on Health Services Accreditation is considered a gold star for hospitals across the country. As the newest amalgamated hospital organization in Ontario, the Niagara Health System is justifiably proud of achieving Accreditation status so soon after eight separate organizations merged.
The Three Year Award for the NHS follows an extensive and intense review process that included a self-assessment as well as on-site surveys and interviews held in June. The survey and overall review was led by a six member team of certified surveyors made up of two physicians, two hospital administrators and two nurses from across Canada.
"This is a tremendous achievement for our young organization," exclaimed NHS Board Chair Mark Newman. "Our accreditation success is the result of team effort. We truly appreciate the work of everyone who contributed to receiving this important award."
In their remarks to the NHS immediately following the June survey, the surveyors were expansive in their praise for the hard work to date in bringing together the hospital sites. "You are brand new," said surveyor Vickie Kaminski, "and you've done a tremendous amount of work. There is no question that everyone is working flat out." The NHS celebrated its second birthday in March 2002.
More than 300 employees, physicians, representatives from partner health care agencies and members of the public participated directly in the accreditation process, explained Mary Parker, NHS Vice President of Health Programs. "We started working on the assessments and preparing for the survey more than a year and half ago." Mrs. Parker noted that twelve accreditation teams were brought together to work collaboratively on the assessments and surveys. Community members also helped out by participating in focus groups that were led by the surveyors.
The results of the 2002 Accreditation Survey applauded the NHS for a number of achievements and also identified areas where system-wide improvements should be made.
Achievements include:
- Commendation for improvements in utilization practices and the implementation of "Interqual" (a utilization software program that is a clinical set of criteria matching patients' needs to the appropriate level of care) to facilitate more effective bed utilization;
- Recognition of the introduction of patient care maps at most NHS sites as an important achievement in providing quality patient care;
- Recognition of the consolidation of programs as helping to integrate services across all sites and establish consistent standards of quality and care;
- Acknowledgement of the human resources and information management teams for carrying-out system-wide planning;
- Commendation of the new emergency unit at the Welland Hospital as well as the capital plans that are in place for the physical renewal and renovation at other sites;
- Recognition of the financial recovery initiatives that have been implemented;
- Acknowledgement of the medical staff leadership process that is currently underway.
Areas identified through the Accreditation process as needing to be addressed system-wide included:
- The need to address storage is an issue at several sites, particularly reducing clutter to avoid potential risks should any type of evacuation become necessary;
- The need to conduct mock disaster exercises at all sites.
- The need for a formal policy for the conduct of research;
- The need to increase health promotion and disease prevention activities in some areas;
- The need to standardization charting policies and practices system wide; and,
- The need to develop formal system-wide policies and procedures to ensure the appropriate person obtains the client's consent.
"Accreditation has enabled us to make great strides in our vision of becoming an integrated health system. Our focus now is to move ahead and make the improvements that were identified," said NHS President and CEO Larry Tokarchuk. "Through the next several weeks our accreditation teams will reconvene to begin work on our system-wide concerns and more specific matters that were identified to each of our twelve teams. As part of our Accreditation award we will be reporting back to the Canadian Council on Health Services Accreditation on our efforts to address storage issues and on our progress in standardizing policies."