Ross Memorial Hospital Lindsay, Ontario

1. Ross Memorial HospitalLindsay, Ontario Journey into Qmentum

2. Ross Memorial Hospital: Active community hospital Provide services 80,000 residents (City of Kawartha Lakes) Recently completed major expansion; doubled ER dept Schedule 1 mental health facility, new Complex CC wing, CT suite, dialysis unit 218 bed capacity, approx 820 employees. ER visits: over 44, 000 clients per year Lindsay is the largest urban centre in the City of Kawartha Lakes (CoKL), population of over 18,000 Services are provided for over 80,000 residents throughout CoKL, including high number of cottagers Major expansion; doubled ER size/services; opened Schedule 1 Mental Health facility, new Complex CCwing including Palliative and Rehab services, and a newly renovated CT suite. Very proud to have most recently opened a 15 bed satellite dialysis unit. We also have expanded our OP services and have a very proactive supportive team to serve our clients. We may be considered small by some but we work very hard to fullfill the needs of our residents and are a very busy hospital, with our ER dept seeing over 44, 000 clients a year. Lindsay is the largest urban centre in the City of Kawartha Lakes (CoKL), population of over 18,000 Services are provided for over 80,000 residents throughout CoKL, including high number of cottagers Major expansion; doubled ER size/services; opened Schedule 1 Mental Health facility, new Complex CCwing including Palliative and Rehab services, and a newly renovated CT suite. Very proud to have most recently opened a 15 bed satellite dialysis unit. We also have expanded our OP services and have a very proactive supportive team to serve our clients. We may be considered small by some but we work very hard to fullfill the needs of our residents and are a very busy hospital, with our ER dept seeing over 44, 000 clients a year.

3. The RMH Journey begins��. Nov 2007: Accreditation Co-ordinator- roles Knowledgeable about the process, become the expert! Provides guidance and education Acts a primary contact with AC Co-ordinates portal access for team leaders/ staff Co-ordinates survey, instrument and indicator submission. Senior leadership support AC needs direct access to a senior leader Assist with overcoming barriers Provide support for decisions made Communicate information to board members, staff, managers, physicians So now that I have shared a little about our hospital, I�d like to tell you a bit about our journey into Qmentum process, how we started, making the change from the old Accreditation process, sharing some successful strategies and what our planned next steps will be. So now that I have shared a little about our hospital, I�d like to tell you a bit about our journey into Qmentum process, how we started, making the change from the old Accreditation process, sharing some successful strategies and what our planned next steps will be.

4. Accreditation Co-ordinator launches the journey�.. Learning opportunities: AC, other organizations Connect with Accreditation Specialist (AC) Set a time-line- senior team direction Champion the process Educate team leaders, Program Directors, Senior administration team, board members, staff CHANGE�..benefits expected for organization/ clients; risk assessment, quality improvement, focus on PATIENT SAFETY. Be available!!!

5. Key highlights of the journey��. 36 month ? 10months Org Portal open; mid-Nov 2007, 15 standard sets selected, teams registered, access to standards, Approx 1 month for educational sessions Mid Dec � end-Jan; Completed self assessment against standards AND completed the patient safety culture survey. On-line surveys completed, utilizing direct link to AC website; instructions sent via email or posted on computers.

6. Survey Instruments/ Self assessment Instruments: Patient Safety culture/ governance: Governance 100% completion Patient Safety culture: surpassed defined threshold, incentives for completion, common Ross initiative Self- assessment surveys Higher completion rates = more valid or reliable data? Staff unfamiliar with wording/ intention of standards

7. Quality Performance Roadmaps (QPR) Feb 08; QPR�s available on portal Results may be revealing, puzzling, surprising, ask questions QPR assessment by teams: Validate or refute yellow and red flags Develop and implement action plans to address flags Enter action plan/ results into portal

8. Strategies��������. Review QPR with team leaders and teams Monthly team leader meetings/ VP Front line staff dissemination Corporate initiatives: ROP�s, G&O�s Communication mechanisms: Monday report, unit meetings, safety huddles, bulletin boards, departmental program meetings (community representatives), Patient Safety newsletters, general staff meetings. CAMPAIGN: �Pathway to patient safety� challenge. Integrate accreditation standards into meaningful patient safety practices.

9. Mock assessments (staff surveyors) Evidence binders- staff resource, provided information on standards and related practices in place Patient safety walkabouts (2006), included questions related to ROPs Qmentum DVD available to teams/ individuals

10. �Tips� for preparing������� On-site documentation list complete; location of documents Meeting list (Managing Meds, bed flow, orientation) �Bragging boards� Assess proposed survey schedule: recommend comprehensive assessment of program by 1 surveyor One page time table �Buddies�

11. On-site survey (Sept 2008) 3 days with 3 surveyors (inc team leader) Meet and greet Debriefing Final debrief session- increased staff interest; general comments (S&W), written report left on-site, including number of standards met.

12. Post on-site survey activities Feedback to AC � organization commentary 10 days: full written forecast report including surveyors comments Post - survey; QPR in portal Teams/ senior Admin assess flags from on-site survey; refute- validate; action plans to meet standards not met. 6 months from receipt of written report; corrective actions assessed; accreditation status award (Apr/May 2009)

13. How does the journey end? Quarterly Qmentum team leader meetings Implement new ROP�s (2009) Rough schedule; 3 year cycle (May 09-May 2012) Patient Safety, Quality Improvement and Risk assessment tools or resources Qmentum is an ongoing process�. providing an organization with a vision or goal to meet best practices It doesn�t end.It doesn�t end.