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Oncology, Chronic Kidney Disease programs achieve maximum accreditation, praised for commitment to quality

Posted Jul 7th, 2008

Niagara, ON - The Oncology and Chronic Kidney Disease programs of the Niagara Health System (NHS) have been thoroughly measured against national health-care standards and have met every standard for the maximum three-year accreditation.

"Our Oncology and Renal health-care teams are skilled professionals who take great pride in the quality of the care and service they provide patients and their families," said NHS President and CEO Debbie Sevenpifer. "We are very pleased with the results of our first accreditation survey for these two programs which are new to the NHS. This process validates that we are meeting or exceeding all of the Canadian standards identified through the rigorous accreditation process."

The Canadian Council for Health Services Accreditation (now called Accreditation Canada) issued its final report this week, the final stage of a process that included a self-assessment by the teams and on-site visits by two surveyors. Both teams received praise and recognition for their hard work and continued commitment to quality improvement.

The surveyors evaluated the programs' performance in such areas as patient safety, setting goals and achieving results, delivering services and addressing patients' needs. "Both the renal and the oncology programs are very strong and both teams are aware of where improvements need to be made," the surveyors wrote in their report.

The Chronic Kidney Disease program scored high in such areas as being responsive to patient needs, being a proponent of patient choice and empowerment, and offering patient education sessions. The program was applauded in the report for the comprehensive planning activities it has undertaken with input from a variety of disciplines and based on health data for the region. "This team has done a lot of planning for the future of this program," the report says.

Among the areas for improvement, to consider the team's wish for a dedicated educator to support the program rather than continuing to use senior staff to facilitate educational sessions and training; and to monitor the staffing challenges in pharmacy, social work and dietitian associated with the growth of the program.

The Oncology program scored high in such areas as holding focus groups with patients around planning for the new health-care complex, ongoing monitoring of wait times for services, improving the intake of women in the Ontario Breast Screening Program (OBSP), coordination of care with other care providers in the community, and the use of patient satisfaction surveys to enhance quality of care.

Among the areas for improvement, to continue to engage patients and families in aspects of the program planning process, to continue to participate in prevention and promotion activities with community partners, and to continue to use data for planning to ensure the team is meeting the needs of the community.

Organizational successes highlighted in the accreditation report include the signing of a Memorandum of Understanding with Hamilton Health Sciences and Cancer Care Ontario for integrated regional cancer services, the opening of new dialysis unit at the Welland Hospital Site and nursing recruitment and retention. "A reduction in the nursing position vacancy rate to 5.5 percent is a significant accomplishment," the report says.

"The accreditation process is very intensive but well worth the investment of time and effort," says Frank Demizio, Vice President, Patient Services. "This process provides us with valuable independent feedback from which to focus our continuous quality improvement efforts. This accreditation award clearly demonstrates that we are providing our patients with a consistently high standard of care."

The accreditation process for the Chronic Kidney Disease and Oncology programs was separated from the overall NHS accreditation process in 2006-07 because the programs were new to the organization at that time. With this latest accreditation award, all NHS programs are now accredited by Accreditation Canada. A separate accreditation process for NHS laboratories resulted in full accreditation in October 2007 for five years by the Ontario Laboratory Accreditation (OLA).

Niagara Health System