Download Information for Staff Accreditation 2016 WRHA Cardiac Sciences Program

Information for Staff
WRHA Cardiac Sciences Program
Accreditation 2016
What Do I Need to Know About the Site Visits?
Even if your area is not one of the sites selected by Accreditation Canada for a scheduled visit,
individual staff members may still be contacted by the Surveyors to participate in the accreditation
process. We all need to be prepared
his/her experiences with particular aspects
of service, such as intake/admission,
Twenty eight surveyors from Accreditation
assessment, care planning, communication
Canada will be in Winnipeg from April 17- 22,
with and between service providers,
2016. Quite a busy week for them!!
referrals to other services, etc.
What will the Site Visit process look
like? The Cardiac Sciences Program will be

The surveyor will review the file to look for
documentation related to service.
surveyed on April 20, 2016. Three surveyors
will be visiting the following areas:

The surveyor will ask to meet with individual
staff involved in providing service to the
patient and ask general questions about
how service is provided, such as “When you
first receive a referral, how is the intake
handled?” The surveyor may then use ‘drilldown’ questions to gain a deeper
understanding of how the process of intake
works—what paperwork is done, who
information is collected from, etc.

The surveyor may ask the staff person to
take them to meet another staff person who
was next involved with the patient. For
example, if an inpatient was sent for
diagnostic tests, the surveyor may want to
go to the lab and speak to the person who
drew blood, to ask about processes such as
paper requisitions, etc.

If a patient was referred to an outside
service, such as the Cardiac Rehab, the
surveyor may want to phone staff at the
other agency to ask questions about how
referrals from the WRHA come in, what
paper work is provided and how
communications are shared between WRHA
and the outside agency. .

In addition to ‘clinical tracers’ which use the
patient record to trace an episode of care,
surveyors may also be conducting
‘administrative tracers’. In such cases, the
surveyor may also ask staff questions about
how a particular policy is operationalized,
such as PHIA, or they may ask about an
organization-wide initiative such as hand
hygiene and how it is communicated to staff
and patients.

ICCS will be surveyed from 0800-1200.
The Required Organizational Practice
(ROP) of Medication Reconciliation will
be one of their focuses. This ROP
needs to be completed on admission,
transfer and discharge from the unit.

The Perioperative Services (which
includes Cardiac Surgery Inpatient Unit,
Heart Catheterization and Cardiac
Implant Labs) will also be surveyed from
0800-1200.

Clinic areas will be surveyed from 13001600. The areas include Y2, Asper CR1
and CR3.
A ‘typical’ site visit might look something like
this:

The surveyors will arrive at SBH at 0730 on
April 20, 2016. The main boardroom will be
their home base for the site visit.

We have “Buddies” assigned to the
surveyors: Belinda Landry, CEI ICCS, Irene
Nazarevich, CRN CSIU, Greg Vachon, CRN
Pre/Post Area and Barb Knight, CRN Clinic.

The surveyor will review 5 or 6 patient files
that have been pre-selected. The files are
preselected based on the following criteria:
complexity, number of medications,
diagnosis, patient’s age and service. The
surveyor will select one file to use to conduct
a Tracer.

The surveyor will meet with the patient, and
perhaps family members, to ask about
Information for Staff, Accreditation 2016
#4 April 11, 2016

The surveyor may observe staff interactions
with patients on a unit, or ask to sit in on a
home-visit with a patient. The surveyor may
even sit in and observe a team meeting and
use the opportunity to meet with several
staff at one time to ask questions.
How is staff involved? As you can see
from the above description, staff is an important
part of the accreditation process. If the surveyor
chooses to review one of your patients, you may
be directly involved in the process at the site
visit. If your name appears in the selected
patient file, for example on a hospital discharge
summary in a patient record, the surveyor may
contact you by telephone to talk about
information sharing, or discharge planning. It is
even possible the surveyor may travel to the site
to meet with you.
What will the Surveyor focus on?
The surveyors will focus on Required
Organizational Practices or ROPs. ROPs are
essential practices that organizations must have
in place to enhance patient/patient safety and
minimize risk. More information about the ROPs
that apply to Cardiac Sciences Program will be
coming in the next accreditation staff update.
We all have to be prepared. We cannot
be certain which patient files the surveyors will
choose, which processes they will follow, or to
which sites the processes will lead them. This is
why we all have to be prepared for
Accreditation. If you have questions about
Accreditation, please contact your Program
Team Manager.
SAMPLE Questions a Surveyor
MAY ask Staff:

Could you tell me who your patients are?

How do you determine a patient’s needs and
expectations?

Could you describe your assessment
process? Who is involved?

Describe your approach to planning care.

How are the goals for service identified?

How do you involve the patients in the care
planning process?

How do you identify possible victims of
abuse?

How does your discharge/transition process
work? When is it initiated?

What is your link with the community, or
hospital? How do you ensure your patients
are referred to the appropriate organization?

How do you ensure patient safety during
transfer to another facility?

How does the multidisciplinary team
facilitate communication with other patient
service delivery centres?

Describe your follow-up process with a
patient that is discharged from your service.
Remember!
Surveyors are not evaluating individual staff
competency or the care provided to
particular patients/patients.
Tracer methodology enables surveyors to trace
care and services delivered to a specific patient.
Through this exercise the surveyor is able to
gauge how well an organization complies with
standards and operationalizes its own policies.
Information for Staff, Accreditation 2016
#4 April 11, 2016