BULLETIN – INFECTION PREVENTION & CONTROL

Infection Prevention and Control (IPC) is one of our Accreditation Themes. It covers hand hygiene education & training, compliance with accepted practices, and infection rate tracking and analyzing. Within the IPC there are 3 Required Organizational Practices (ROPs) that must be met to successfully complete our Accreditation which will occur October 17 – 21, 2022.

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

Kim Scott (Chair), Smitha Varghese, Anitha T, Leanne T, Angela R-F, Linda W, Trish G, Moreen R, Annette F, FHA IPC representative.

How will the ROPs be evaluated?

Surveyors will tour Menno Home & Menno Hospital and test compliance for each of the ROPs. Specifically they will gather information by:

• Talking and listening to team members, families, residents, volunteers, and community partners such as physicians, pharmacists, and contractors.
• Observations of what is taking place as they tour the sites
• Reviewing resident health records and/or Employee files

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

Surveyors will meet with team members, residents, families, students and volunteers so everyone should be aware of this IPC theme and the associated ROPs and priority practices. If you are asked a question on an unfamiliar topic, please refer the surveyor to the appropriate individual or supervisor.

ROP 1  Hand Hygiene Compliance

How does Menno Place evaluate compliance with accepted hand hygiene practices?

Menno Place evaluates hand hygiene compliance by directly observing the practice using their Speedy Audit tool.

Evidence: How does Menno Place do this?

• We have a written policy available on SharePoint:  Infection Prevention & Control Program AP 5.05
• We have trained Hand Hygiene auditors who regularly conduct peer audits
• Audits are reviewed with the Infection Prevention and Control Committee, sent to leaders, and then shared with team members at unit team meetings and department meetings
• Audits are posted on our bulletin boards and visible to residents, families, visitors, and volunteers
• Concerns and trends are followed up on
• Our audits provide valuable information to our leaders and staff in developing and implementing strategies to improve hand hygiene. For example, based on feedback, we have installed more hand sanitizers in targeted areas.

ROP 2 Hand Hygiene Education & Training

What education and training have Menno Place staff received on hand hygiene?

Menno Place staff receive regular education assigned to them in Surge Learning, they have visual signs posted throughout the site, they receive hands on education at unit team meetings, and direct feedback by hand hygiene peer auditors.

Evidence: How does Menno Place do this?

• Annual Hand hygiene education for all staff and volunteers
• Hand hygiene education at orientation and on Surge Learning (ongoing)
• Annual COR certification
• Hand hygiene is discussed with all families during move-in
• Posters throughout the building
• Hand hygiene is discussed at family councils and resident councils
• Education – Fact sheet – posted in Newsletter

ROP 3 Infection Rates are Tracked and Analyzed

Does Menno Place track infection information, analyze it, and communicate this information throughout the organization?

Yes, Menno Place tracks infection rates, analyzes the information to identify clusters, outbreaks and trends; this is shared throughout the organization.

Evidence: How does Menno Place do this?

• We track infections by completing the infection log monthly
• Complete infection surveillance sheets for all infections
• We have an Infection Prevention and Control Committee where we analyze monthly data
• All outbreaks are reported to our Infection Control Lead (Kim Scott), who follows up according to the infection control manual’s outbreak management guidelines from FHA
• Outbreaks are managed in partnership with health authority medical health officers.
• Infection rates are displayed on a report sheet every month; the graph is shared with team members at unit/department meetings.
• Outbreak information is shared at monthly Leadership team meetings and quarterly at the Quality Improvement Risk Management Board committee (QIRM).
• We have a Policy: APS 5.05 – Infection Prevention and Control Program

 

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 care home?
• Do you know where the hand hygiene audit results are posted?
• How easy was it for you to get your flu/covid vaccination at work?
• What would you do if you suspected a co-worker or resident had an infectious disease?

Thank you for your part in making this Accreditation Survey another successful one!

BULLETIN – SAFETY BULLETIN

SAFETY CULTURE

Safety is one of our Accreditation Quality Dimension. It focuses on creating a culture of safety at Menno Place. Within the safety quality dimension there are 4 Required Organizational Practices (ROPs) that must be met to successfully complete Accreditation which will occur October 17-20, 2022.

How do we comply with the Safety ROPs?

Menno Place has dedicated resources to adopt and implement a variety of safety reporting measures including reporting events and disclosing them. Safety is embedded in Menno Place’s Strategic Plan. Leaders regularly report to the Quality Improvement Risk Management Committee (QIRM) on safety concerns and provide recommendations and progress reports on key initiatives in process. Additionally, leaders provide detailed review on all the quality indicators.

How will the ROPs be evaluated?

Surveyors will tour Menno Home & Menno Hospital and test compliance for each of the ROPs. Specifically they will gather information by:

• Talking and listening to team members, families, residents, volunteers, and community partners such as physicians, pharmacists, and contractors.
• Observations of what is taking place as they tour the sites
• Reviewing resident health records

Who needs to be aware of the Safety Culture ROPs?

Surveyors will meet with teams, physicians, staff, residents, families, students and volunteers so everyone should be aware of the Safety Quality Dimension and the associated ROPs and priority practices. If you are asked a question on an unfamiliar topic, please refer the surveyor to the appropriate individual or supervisor.

ROP 1  Accountability for Quality

Does the Menno Place Board have a demonstrated commitment to quality performance in the organization?

Yes, the Board of Menno Place demonstrates a clear commitment to quality by having it as a standing item on the agenda of its meetings.

Evidence:  How do we do this?

• The Board is engaged in overseeing quality in order to ensure that quality performance continually improves. Governing bodies are accountable for the quality of care provided by their organizations. The Board is aware of key quality and safety principles in order to understand, monitor, and oversee the quality performance of the organization.
• The Board has a clear commitment to quality as evidenced by having it as a standing item at each meeting.
• The Leaders and Board review a number of indicators on a regular basis.
• Resident safety is embedded in the Menno Place strategic plan.
• Menno Place’s quality performance indicators are directly linked to strategic goals and objectives. Knowledge gained from the review of quality performance indicators (i.e. data collected on number of falls, pressure ulcers, restraints, sick time, injuries etc.) is used to set the agenda, inform strategic planning, and develop an integrated quality improvement plan. Resource allocation may be determined by priorities arising out of evaluation of quality performance.
• Menno Place has a Quality Improvement and Risk Management Committee (QIRM). This committee consists of Senior Leaders and Directors and Board members and meets quarterly. The QIRM committee reports to the Board.

ROP 2 Workplace Violence Prevention Program

Does Menno Place have a documented and coordinated approach to prevent workplace violence?

Yes, Menno Place does have a documented and coordinated approach to prevent workplace violence.

Evidence:  How do we do this?

• We have written policies, available on SharePoint: Workplace Violence Prevention AP 3.41 and Workplace Harassment and/or Bullying AP 3.43
• Risk assessments are conducted to determine and identify the risk of workplace violence
• Staff are educated and trained on workplace violence prevention through Surge learning and hands on workshops.
• The JOHS committee regularly reviews policies, incidents, and conducts audits and assessments to prevent workplace violence.

ROP 3 Client Safety Incident Disclosure

Does Menno Place have a documented and coordinated approach for disclosing client safety incidents to residents and families?

Yes, Menno Place has a policy “Disclosure of Harm or Near Miss” AP 2.28, available on SharePoint.

Evidence:  How do we do this?

• Disclosure is the process used by Menno Place to inform a resident and/or their family of a specific harmful incident. During this process the implications of that incident are discussed in a respectful, sensitive, and thorough manner. Part of the process involves support for residents and staff as well.
• Menno is committed to honest and open communication with residents and families when harm occurs. This may include a fall with injury, medication error, unexpected death, missing resident, theft, etc.
• A complete, accurate, and factual account of the disclosure discussion(s) is recorded in the resident’s health record.
• An example of support to resident’s, families, and team members includes emotional/psychological support by social worker, 3^rd party counseling service such as the Employee Family Assistance Program, and/or spiritual care.

ROP 4 Resident Safety Incident Management System

Are there processes in place to review client safety incidents, recommend actions and monitor improvements?

Yes, Menno Place addresses client safety incidents and takes action to reduce any risk of recurrence.

Evidence:  How do we do this?

• Menno Place encourages everyone to report and learn from resident safety incidents including harmful, no-harm and near miss. The reporting system is simple, clear, confidential, and focused on system improvement.  Residents and families are also encouraged to report.
• We have written policies, available on SharePoint: Incident Reports RCS 1.09, Reportable Incidents RCS 1.14, and Safety of Residents RCS 2.01.
• We utilize resources from the Canadian Patient Safety Institute and learns from shared client safety incidents from other sources.
• Broadly communicating incident analysis internally and externally in order to build confidence in incident management and promote collective learning.

What are some of the questions surveyors may ask about Safety Culture?

During the onsite visit, surveyors will ask questions about Menno Place and how they comply with the ROPs and standards. A sample of questions may include the following:

• Do staff feel there is a no blame culture?
• Are there open discussions about resident safety issues in each neighborhood?
• What can you tell us about the incident reporting system at Menno Place?
• Can you tell me about an improvement initiatives that has occurred in your work area over the past year?
• Have you reported any near miss incident? Can you give an example?
• Can you define a harmful event?

Thank you for your part in making this Accreditation Survey another successful one!

BULLETIN – ACCREDITATION – THE 5 ‘Ws’

WHY

We want to BEE the best! Being accredited allows Menno Place to be measured against world class evidenced based health care standards. The goal is to provide the best healthcare and services to our residents so we can do what we do best: care for and improve lives.

WHEN

Save the Date: Oct 17^th to Oct 21^st, 2022

These are the dates the Accreditation surveyors will be on the Menno Place campus site. Preparation is already underway and will continue until then. Stay connected by reading the Bulletin updates on the Family and Friends website – www.MennoPlaceLife.com

WHERE

Onsite at Menno Home and Menno Hospital in all areas of care, services, and support.
Will you BEE prepared?

WHO

Accreditation Canada (AC) is an independent, non-government, not-for-profit organization affiliated with Health Standards Organization (HSO), located in Ottawa, Ontario. AC is committed to inspiring people to make positive change that improves the quality of health and social services in Canada and around the world. HSO develops world-class and evidence-based standards, assessment programs, and quality improvement solutions. AC and HSO use a People-centered care philosophy and approach to setting its standards and guiding the accreditation process.

WHAT

The Accreditation Tool is organized into six chapters:

Chapter 1: Governance and Leadership

Addresses criteria assessed by governing bodies and/or leadership teams and defines the standards under which the organization or LTC home’s management operates.

Chapter 2: Delivery of Care Models

Addresses thematic areas related to team management, talent development, work-life, information management, quality improvement and delivery of virtual health services.

Chapter 3: Emergency Disaster Management

Addresses emergency, disaster, and outbreak management, focusing on reducing risk and being prepared to respond to and recover from an emergency, disaster or outbreak that occurs inside or outside of the organization.

Chapter 4: Infection Prevention and Control

Addresses organizational infection prevention and control (IPC) practices that promote a collaborative approach in providing safe and reliable services and preventing transmission of pathogens and health care-associated infections.

Chapter 5: Medication Management

Addresses organizational medication management practices that promote a collaborative approach in providing safe and reliable services.

Chapter 6: Residents’ Care Experience

Focuses on ensuring the needs of LTC home residents are met by providing safe and quality individualized care from competent teams.

These chapters are further broken down into eight quality dimensions that all play a part in providing safe, high-quality care.

1. Population focus: Work with my community to anticipate and meet our needs
2. Accessibility: Give me timely and equitable services
3. Safety: Keep me sage
4. Work-life: Take care of those who take care of me
5. Client-centred services: Partner with me and my family in our care
6. Continuity of services: Coordinate my care across the continuum
7. Appropriateness: Do the right think to achieve the best results
8. Efficiency: Make the best use of resources

Watch for these themes to come in future bulletins.