At SHN, we demonstrate our commitment to exceptional care for our patients every single day. One of the ways in which we commit to quality is by undergoing a voluntary evaluation—Accreditation.
The last time we were accredited was in 2016 before the merger of our hospitals. When the pandemic struck, our on-site survey was deferred. With quality and safety at the heart of every decision we make, we knew we needed all hands on deck.
With the hardest times now behind us, we are thrilled to share that, during the week of November 14-18, surveyors from Accreditation Canada will be visiting SHN. This will be the very first time we go through this process as one connected network, and we could not be more excited!
We wanted to give you a peek behind the curtain to show you one of the ways that we prepare for Accreditation—mock tracers!
SHN’s Accreditation team recently hosted their first round of mock tracers. Over the span of four weeks, more than sixty leaders and staff were involved in tracers, visiting over thirty units across all three hospitals.
As part of their preparation, mock surveyors were offered tracer kits and checklists to help guide conversations and questions with SHN staff. As they journeyed through their assigned units, they were given the opportunity to observe daily practices and identify strengths and areas of opportunity across the organization.
At SHN, safety is everyone’s business. This unique and exciting opportunity allows our staff to follow the patients’ experience while in SHN’s care. Mock tracers are also a great opportunity to recognize and celebrate staff for a job-well-done! “It was an opportunity for us to know what we are doing well and where we can improve as a unit and as a department. This will not only help us be better prepared for the real survey in November, but it has also helped boost staff morale!” said Vevien Braga, Manager, CCU.
Mock tracers are also a way to engage staff, while fostering a culture of safety and quality, and facilitating organizational learning. “Our mock surveyors complimented our hand hygiene practices and the cleanliness of our unit. It was refreshing to hear this as we strive to do our best in these areas to contribute to patient protection and safety”, said Christina Petrus, Registered Nurse, CCW.
The Accreditation Team is very thankful to the staff who were a part of this initiative. “The first round of our mock tracers were completed with much success. Overall, staff and physicians were friendly, engaged and knowledgeable about relevant policies and procedures as they relate to our Required Organizational Practices”, said Natalie Quan, Manager, Patient Safety & Accreditation Lead.
The Accreditation Team will be working with all programs and departments to address actions based on results received from the mock tracers and will explore the opportunity to conduct a second round of unit tracers before the on-site visit in November.
With this unwavering focus on quality and patient safety, we look forward to celebrating another successful Accreditation survey in 2022 as one connected network!
Accreditation is an ongoing process of evaluating and recognizing a hospital’s programs, services, policies and procedures as meeting established standards. As a roadmap to quality, Accreditation Canada’s Qmentum provides evidence-informed standards, tools, resources, and guidance to healthcare organizations on their journey to excellence.
Accreditation is a process of continuous quality improvement. Although it is a voluntary process, almost all healthcare organizations in Canada and around the world participate to evaluate and improve quality and safety of services. One of the benefits of Accreditation is that it highlights areas of excellence as well as gaps in the programs and services that an organization offers.
“A process for collecting information that involves following the path of either a patient or an administrative process throughout the continuum (of care) within a healthcare setting to assess organizational performance against relevant standards.”
- To validate that the standards are being met
- Allow a “fresh” set of eyes to identify strengths and quality improvement opportunities
- Offer an objective peer review
- Gather a comprehensive view of all areas of SHN and how they relate
- Experience what a patient/client experiences at different points in the care continuum
- Investigate the source of an issue or problem
- Assess the effectiveness of policies, procedures or quality improvement initiatives
- Assess whether policies and procedures are consistently implemented across the organization
- Assess communication within and between governance, leadership, departments, units, programs, and services