Accreditation Report. Quality Improvement Plan & Benchmarking Data. Prepared for The Pines Long Term Care Home

Transcription

1 INTERNATIONAL

2 Report Quality Improvement Plan & Benchmarking Data Prepared for

3 Decision Three-Year Expiration: May 31, 2020 Organization 98 Pine Street Bracebridge ON P1L 1N5 CANADA Three-Year Organizational Leadership Christina Rochette, Program Manager Katherine Rannie, Administrator Dates April 6-7, 2017 Team Frank E. Gainer, M.H.S., OTR/L, FAOTA, Administrative or Brock W. Hall, Program or Programs/Services ed Person-Centred Long-Term Care Community Previous March 6-7, 2014 Three-Year

4 Summary Areas of Strength has strengths in many areas. The organization is complimented on how it has embraced the performance improvement process. The organization is evaluating numerous initiatives to improve a variety of processes that impact the quality of services offered to persons served. There is an obvious commitment to health and safety. Inspections are completed monthly, areas for improvement are summarized, and follow-up action is evident. This aggressive program allows the organization to maintain the physical plant and equipment in a timely manner. There is a comprehensive strategic plan that is expected to serve the organization well as it moves into the future. There is a comprehensive volunteer orientation program. has a large volunteer cadre that allows it to offer a variety of activities and one-on-one services to its residents. Also noted were a variety of activities for the residents, with significantly more programming than most organizations of its size. A very active Resident Council provides the organization with excellent feedback on ways to improve its services. The staff has proven to be very responsive to the issues raised. The Resident Council members noted that they were well supported by the staff and management. The organization is congratulated on its outstanding telemedicine program. This is an exceptional program in that it allows residents easy access to specialists without having to leave the premises. Although very few in number, all complaints are taken seriously and handled in an expeditious manner. The organization is complimented on the high return rate for its satisfaction surveys from residents and family members. The leadership team takes this information, analyzes it, and acts upon it to further improve care to the persons served. The organization has become very transparent in sharing this information with all interested parties. A good first impression is made when one enters the main doors of and is promptly greeted by the receptionist. Well-appointed tables and chairs outfit the Country Kitchen for residents and guests to enjoy coffee, tea, and snacks. This is a popular gathering place for people to visit. The residence is well maintained and enhancements have given it a warm, homelike ambiance. The Muskoka Room is decorated with items that residents would recognize from their youth. There are extensive outdoor spaces for enjoyment of residents and their family members. There are fish, birds, and a recently acquired housecat, Ginger, for the residents to enjoy. Resident living areas are clean, bright, warm, and inviting. The basic rooms were thoughtfully designed so that each resident has his/her own private sitting and sleeping area. The organization has frequent communication with family members. It has made great efforts in collecting the necessary contact information, and the families appreciate the information that is shared. Report 1

5 The organization has implemented an exceptional method for documenting the review of its contractors. The Contractors Health and Safety Performance Review form has turned into a 360- degree review, and the organization and contractors both benefit from this process. The organization also has a creative performance evaluation process. Every other year, a Read & Sign evaluation is done where staff members complete training updates and have the opportunity to develop additional goals and objectives. The meals are nutritious and the residents wishes are taken into consideration. The Delightful Diners group provides valuable input to the dietary and food service staff. Although the population of residents has very little diversity, when diversity does occur, the staff acts to accommodate the differences in a very thoughtful and thorough process. Persons served expressed feelings that they are well cared for by staff and management. At the time of admission, each person served and family member is given a user-friendly handbook that is clear and well organized in order to introduce them to their new residence and lifestyle. The organization has made a concerted effort to keep its residents well connected with the community. This is evidenced by the fact that it has more than 165 active volunteers. Several churches and numerous other organizations, such as the local Central Muskoka Legion, are a key part of regular programming. Several supporting healthcare partners, such as the physiotherapy provider, are tightly integrated within the care teams. Communication by the care teams is both appropriate and timely. The new addition, built since the last survey, gives the opportunity to have the space needed to offer large group programs to persons served, office space for support staff, and much-needed storage. The new Country Kitchen was noted to be a good gathering area for family, staff, and residents. Families noted they feel their loved ones are very well cared for by all departments. Even though there is currently no family council in place, families receive regular communication from the administrator that keeps them well informed. There is a confidence that services are being improved. Families commented that the phrase everyone knows your name is very applicable to the way they are made to feel by staff. Staff members noted that they feel they are well oriented when becoming new to the staff and regularly trained both to meet regulatory requirements and to ensure that they know how to work safely. Staff members appreciate the survey that seeks their input, and they hear the results of those surveys. They also see that they are supported by management via an open-door policy and a responsiveness to their issues. Staff training is a strength as evidenced by conformance to legislated annual training requirements. The organization is commended for having trained most staff on the Gentle Persuasive Approach, which has helped to effectively manage behaviours in this setting. 2 Report

6 Areas for Improvement should seek improvement in the following areas. Although the ministry requires reconciliation be done on a quarterly basis, the organization takes responsibility for the funds of persons served, and it should implement written procedures that define how monthly account reconciliation is provided to the persons served. The organization performs fire drills and emergency evacuations, but other emergency procedures are not being tested on an annual basis on each shift and location. The organization s unannounced tests of emergency procedures should be conducted at least annually on each shift and at each location. The tests should include complete actual or simulated physical evacuation drills and be analyzed for performance that addresses areas needing improvement, actions to be taken, results of performance improvement plans, and necessary education and training of personnel. The tests should be evidenced in writing, including the analysis. The organization currently reviews contracted personnel at the time of renewal of the agreement. The organization s performance management should include reviews of all contract personnel utilized by the organization that are performed annually. The organization makes phone calls to some of the families of persons served post service provision, yet this is not being done consistently. is urged to collect data about the persons served at the end of services. Decision has earned a Three-Year. On balance, has made a commitment to conform to the standards. Leadership is responsive to residents, their family members, and the staff and their needs. The longevity of the frontline team members results in consistent, quality resident care and contributes to overall resident and family satisfaction. The organization has embraced the performance improvement process, and it has numerous initiatives it is working on to improve the quality of services offered to persons served. The positive attitude with which the management and staff prepared for and participated in the survey and their receptivity to the consultation, suggestions, and information on areas for improvement that were offered instil confidence that the organization will use the opportunities for improvement noted in this report and the CARF standards as guidelines for continuous quality improvement. Report 3

7 Consultation Section 1. ASPIRE to Excellence A. Leadership is encouraged to evaluate alternative formats for documenting its cultural competency and diversity plan. This could allow it to more easily update various initiatives that are occurring on a regular basis. C. Strategic Planning The organization might consider evaluating other methods for providing regular updates to its strategic plan in order to better track progress. G. Risk Management might want to consider reformatting its risk management plan in order to provide more consistent updates as needed. L. Accessibility The organization may benefit from assessing how to better track updates to its accessibility plan. Consultation does not indicate non-conformance to standards but is offered as a suggestion for further quality improvement. 4 Report

8 Standards Conformance This section of the Report displays the specific reasons for any partial or non-conformance to standards identified as a result of the survey. The standards listed in this section are addressed in the organization s Quality Improvement Plan, which can be accessed at customerconnect.carf.org. Below are the possible reasons for partial or non-conformance to standards, along with an explanation of why each reason is cited. To receive the information contained in this section in an alternate format, please contact editing@carf.org. Reason for partial or non-conformance Procedure/practice not developed Is cited: When a standard element requires a procedure/practice, it is not in existence. Policy/plan not developed Policy/plan/procedure/practice not implemented Policy/plan/procedure/practice recently implemented Policy/plan/procedure/practice not consistently implemented Frequency inadequate Documentation inadequate When a standard element requires a policy/plan, it is not in existence. When a standard element requires a policy/plan/procedure/practice, it exists but there is no actual performance. When a standard element requires a policy/plan/procedure/practice, it exists but the actual performance has not been in place for sufficient time to establish a track record. When a standard element requires a policy/plan/procedure/practice, it exists but the actual performance does not occur with sufficient regularity to be deemed standard operating procedure. When a standard element requires that an activity occur with a specific frequency or some unspecified regularity, the performance of the activity does not occur, occurs less frequently than required, or occurs less frequently than appropriate if regularity unspecified. When a standard element requires documentation or that documentation contain specific information, the documentation either does not exist or does not contain the specific information. Training inadequate Involvement by appropriate person(s) inadequate Data or information necessary to address conformance not collected and/or evaluated Effort not comprehensive Financial ratio calculation below the median Information not communicated understandably Non-compliance with law, regulation, or other rule Credentials inadequate Evidence of conformance inadequate When a standard element requires that certain training occur, it either does not occur or does not occur with sufficient regularity to be deemed standard operating procedure. When a standard element requires the involvement of certain persons, those persons are either not involved or not involved in a sufficient manner. When the issue addressed by the standard element has not been considered and, consequently, the information necessary to address conformance has not been collected and/or evaluated in connection with the issue addressed. When a standard element requires an activity to occur, the performance of the activity is insufficient to address the full scope of the activity. When the standard element rating is based on the calculation of a specific financial ratio, such ratio is below the 50th percentile. When a standard element requires that information be shared with certain persons, the information is either not shared or not shared in a manner that allows for comprehension by the recipient. When a standard element requires compliance with a legal requirement or a process for achieving legal compliance, sufficient evidence of compliance or the compliance process is not demonstrated. When a standard element requires that an individual possess a specific credential or level of credential, the specific credential is not possessed, or the credential possessed is below the specified level. When the requirement of a standard element is not satisfied, or is inconsistently satisfied and no other reasons apply. Report 5

9 Standard Number Standard Text Reasons for Partial or Non-conformance 1.F.9.f. 1.H.7.a.(1) 1.H.7.a.(2) 1.H.7.b. 1.H.7.c.(1) 1.H.7.c.(2) 1.H.7.c.(3) 1.H.7.c.(4) If the organization takes responsibility for the funds of persons served, it implements written procedures that define: How monthly account reconciliation is provided to the persons served. Unannounced tests of all emergency procedures: Are conducted at least annually: On each shift. Unannounced tests of all emergency procedures: Are conducted at least annually: At each location. Unannounced tests of all emergency procedures: Include complete actual or simulated physical evacuation drills. Unannounced tests of all emergency procedures: Are analyzed for performance that addresses: Areas needing improvement. Unannounced tests of all emergency procedures: Are analyzed for performance that addresses: Actions to be taken. Unannounced tests of all emergency procedures: Are analyzed for performance that addresses: Results of performance improvement plans. Unannounced tests of all emergency procedures: Are analyzed for performance that addresses: Necessary education and training of personnel. Procedure/practice not developed Policy/plan not developed Policy/plan/procedure/practice not implemented Policy/plan/procedure/practice recently implemented Policy/plan/procedure/practice not consistently implemented Frequency inadequate X X X X X X X X X X X Documentation inadequate Training inadequate Involvement by appropriate person(s) inadequate Data or information necessary to address conformance not collected and/or evaluated Effort not comprehensive Financial ratio calculation below median Information not communicated understandably Non-compliance with law, regulation, or other rule Credentials inadequate Evidence of conformance inadequate 1.H.7.d. 1.I.6.c.(4) 1.M.5.c. Unannounced tests of all emergency procedures: Are evidenced in writing, including the analysis. X X Performance management includes: Reviews of all contract personnel utilized by the organization that: Are performed X X annually. The organization collects data about the persons served at: The end of services. X 6 Report

10 Benchmarking This section of the Report benchmarks your organization s conformance to standards. By comparing strengths and areas for improvement with various comparator groups, benchmarking encourages your organization to improve effectiveness, efficiency, satisfaction, and access. This information should also stimulate discussions among stakeholders focused on better meeting the needs and preferences of the persons served. In addition, benchmarking: Encourages a culture of continuous evaluation and improvement. Accelerates understanding of and agreement on areas for improvement. Helps prioritize improvement opportunities. Shifts internal thinking toward a focus on outcomes. Provides a reference to increase performance expectations. Motivates your team to work collaboratively to surpass benchmarks. This report provides benchmarks (mean % of conformance) for each section of the ASPIRE to Excellence quality framework. * When available, benchmark comparison groups include: All surveyed organizations. All surveyed organizations in the same primary CARF customer service unit. ed organizations with the same ownership type. ed organizations in the same geographic region. ed organizations with similar number of persons served annually. ed organizations with similar staff size. In addition, standards conformance for each organization undergoing resurvey is benchmarked against its previous survey in all standards areas. Benchmark Comparison Groups Primary area of accreditation: Aging Services (AS) Ownership type: Government Entity Geographic region: Canada ON Staff size (FTEs): Persons served annually: To receive the information contained in this section in an alternate format, please contact editing@carf.org. * Excluding Governance. Report 7

11 All surveyed organizations A: Assess the Environment Leadership CARF Three-Year CARF One-Year 88.7% 98.1% Nonaccreditation 79.3% S: Set Strategy Strategic Planning CARF Three-Year CARF One-Year Nonaccreditation 46.3% 81.7% 98.3% 8 Report

12 All surveyed organizations continued P: Persons Served and Other Stakeholders - Obtain Input Input from Stakeholders CARF Three-Year CARF One-Year Nonaccreditation 60.0% 83.4% 99.8% Legal Requirements CARF Three-Year CARF One-Year Nonaccreditation 99.5% 94.7% 88.7% Report 9

13 All surveyed organizations continued Financial Planning and Management CARF Three-Year CARF One-Year Nonaccreditation 69.2% 91.7% 98.8% 99.2% Risk Management CARF Three-Year CARF One-Year 79.7% 97.4% Nonaccreditation 56.0% 10 Report

14 All surveyed organizations continued Health and Safety CARF Three-Year CARF One-Year 84.0% 96.0% 96.7% Nonaccreditation 74.3% Human Resources CARF Three-Year CARF One-Year 87.5% 99.3% 97.6% Nonaccreditation 72.9% Report 11

15 All surveyed organizations continued Technology CARF Three-Year CARF One-Year 85.2% 99.0% Nonaccreditation 63.8% Rights of Persons Served CARF Three-Year CARF One-Year Nonaccreditation 98.6% 93.4% 86.5% 12 Report

16 All surveyed organizations continued Accessibility CARF Three-Year CARF One-Year 74.7% 96.3% Nonaccreditation 50.5% R: Review Results Performance Measurement and Management CARF Three-Year CARF One-Year Nonaccreditation 41.9% 70.0% 98.9% 97.3% Report 13

17 All surveyed organizations continued E: Effect Change Performance Improvement CARF Three-Year CARF One-Year Nonaccreditation 22.0% 41.7% 92.9% 14 Report

18 Other benchmarks A: Assess the Environment Leadership Aging Services Government Entity Ontario 94.4% 98.3% 95.1% 100 to 499 FTEs 97.1% 100 to 499 Persons Served 97.2% S: Set Strategy Strategic Planning Aging Services Government Entity Ontario 100 to 499 FTEs 97.2% 99.5% 98.2% 99.1% 100 to 499 Persons Served 97.8% Report 15

19 Other benchmarks continued Input from Stakeholders P: Persons Served and Other Stakeholders - Obtain Input Aging Services Government Entity Ontario 100 to 499 FTEs 100 to 499 Persons Served 99.7% 99.6% 99.9% 99.6% Legal Requirements Aging Services Government Entity Ontario 100 to 499 FTEs 100 to 499 Persons Served 99.7% 99.9% 99.7% 99.8% 99.5% 16 Report

20 Other benchmarks continued Financial Planning and Management Aging Services Government Entity Ontario 100 to 499 FTEs 100 to 499 Persons Served 98.8% 99.3% 99.3% 99.5% 99.1% Risk Management Aging Services Government Entity Ontario 100 to 499 FTEs 97.2% 99.0% 97.8% 98.5% 100 to 499 Persons Served 97.3% Report 17

21 Other benchmarks continued 96.0% Health and Safety Aging Services Government Entity Ontario 100 to 499 FTEs 100 to 499 Persons Served 95.3% 97.7% 95.1% 96.2% 96.3% Human Resources Aging Services Government Entity Ontario 100 to 499 FTEs 99.3% 97.5% 98.8% 97.2% 98.0% 100 to 499 Persons Served 97.1% 18 Report

22 Other benchmarks continued Technology Aging Services Government Entity Ontario 100 to 499 FTEs 98.4% 99.9% 98.5% 99.6% 100 to 499 Persons Served 98.8% Rights of Persons Served Aging Services Government Entity Ontario 100 to 499 FTEs 100 to 499 Persons Served 97.9% 99.1% 98.1% 98.7% 98.5% Report 19

23 Other benchmarks continued Accesibility Aging Services Government Entity Ontario 100 to 499 FTEs 94.5% 98.0% 96.1% 97.8% 100 to 499 Persons Served 96.4% R: Review Results Performance Measurement and Management Aging Services Government Entity Ontario 100 to 499 FTEs 100 to 499 Persons Served 98.9% 99.3% 98.6% 98.2% 98.2% 97.3% 20 Report

24 Other benchmarks continued E: Effect Change Performance Improvement Aging Services Government Entity Ontario 100 to 499 FTEs 100 to 499 Persons Served 96.2% 95.8% 93.4% 95.3% 92.5% Report 21

25 Previous survey A: Assess the Environment Leadership Current Previous S: Set Strategy Strategic Planning Current Previous 22 Report

26 Previous survey continued P: Persons Served and Other Stakeholders - Obtain Input Input from Stakeholders Current Previous Legal Requirements Current Previous Report 23

27 Previous survey continued Financial Planning and Management Current Previous 98.8% Risk Management Current Previous 97.1% 24 Report

28 Previous survey continued Health and Safety Current Previous 96.0% 96.2% Human Resources Current Previous 92.4% 99.3% Report 25

29 Previous survey continued Technology Current Previous Rights of Persons Served Current Previous 26 Report

30 Previous survey continued Accessibility Current Previous 89.6% R: Review Results Performance Measurement and Management Current Previous 98.9% Report 27

31 Previous survey continued E: Effect Change Performance Improvement Current Previous Section 2. Care Process for the Persons Served A. Program/Service Structure Current Previous 28 Report

32 Previous survey continued Section 2. Care Process for the Persons Served B. Congregate Residential Programs Current Previous Section 3. Program Specific Standards C. Person-Centred Long-Term Care Community Current Previous 99.6% Report 29

33