SAQ #35

HAVE CLIENTS BEEN TOLD WHO IS RESPONSIBLE FOR COORDINATING THEIR SERVICES? GREEN, LOW
SUMMARY OF RELATED STANDARD(S)
6.2 From their first contact with the organization or team, clients and families are informed of the team member who is responsible for coordinating their service, and told how to reach that person.
Process Currently in Place - Evidence of Current Status
* Surgeon’s office
*PAC pamphlet and Surgical Journey booklet redesigned to increase patient awareness and help walk them through the process
*the Handover tool was developed to increase communication of pts history and surgery throughout the PeriAnesthesia areas
*SMART page: surgeon paged to speak to pt and family when necessary
*increased awareness through Sunnybrook Web: My Chart
Improvement Strategy / Action Plan
Reassess in June

SAQ #34

DO TEAM MEMBERS RECEIVE A COMPREHENSIVE ORIENTATION THAT INCLUDES THE EQUIPMENT USED IN THE SURGICAL CARE AREA? GREEN, HIGH
SUMMARY OF RELATED STANDARD(S) 4.2 The team orients new team members about their roles and responsibilities, the team goals and objectives, and the organization as a whole.4.3 The team orients new team members about the safe use of equipment, devices, and supplies used in delivering surgical care services.4.4 REQUIRED ORGANIZATIONAL PRACTICE: Staff and service providers receive ongoing, effective training on infusion pumps.
Process Currently in Place - Evidence of Current Status
• corporate orientation for new Sunnybrook Staff: 8 days
• unit orientation: depends on the needs of the nurse can be 1-3 months. Combination of class and buddy time. Needs are discussed with the orientee, preceptors, educator and manager
• preceptor/mentorship program
• new grad initiative
• George Brown Critical Care course
• Inservices on new equipment and procedures
• Staff will now be recertified q2yrs on pumps Ongoing PeriAnesthesia tours during orientation week for nurses new to Sunnybrook
Improvement Strategy / Action Plan
Reassess in June

SAQ #33

DOES THE TEAM HAVE THE INFORMATION SYSTEMS NEEDED TO DELIVER SURGICAL CARE SERVICES? GREEN, LOW
SUMMARY OF RELATED STANDARD(S)
13.1 The team identifies its needs for new technology and information systems 13.2 Team members receive education and training on information systems and other technology.
Process Currently in Place - Evidence of Current Status
• Staff are educated and trained on the current information systems used at SHSC: EPR, Intranet, WOW (workstation on wheels)
Improvement Strategy / Action Plan
Bed Management System implemented in December-still needs fine tuning

SAQ #32

HOW DOES THE TEAM RESPOND TO PEOPLE WHO ARE WAITING FOR SERVICES? GREEN, LOW
SUMMARY OF RELATED STANDARD(S) 6.8 The team regularly reviews the needs of clients who are waiting for services and responds to those who are in an emergency or crisis situation.6.9 If the team is unable to meet the needs of potential clients or referring organizations, the team explains the reasons, facilitates access to services offered by other organizations, and records the information for use in service planning.
Process Currently in Place - Evidence of Current Status
• There is a cancelled OR task force committee. Patients will be identified on the OR schedule if previously cancelled
• Registration area is adjacent to the waiting room
• Wait and see list is monitored by the OR and specific surgical services ie: ortho
• Ministry standards are followed ie 1A, 1B, 1C
• PACU has 2 RN’s on each shift (24-7) to accommodate more OR’s
• SSSU open Monday 0730-Saturday 11:30
• Pt flow monitors to adjust OR schedule according to needs
Improvement Strategy / Action Plan
March2010-onward
Reassess in June

SAQ #31

DOES THE TEAM HAVE SPECIFIC, COMMON GOALS FOR ITS SURGICAL CARE SERVICES? GREEN, LOW
SUMMARY OF RELATED STANDARD(S) 2.1 The team works together to develop goals and objectives.2.2 The team’s goals and objectives for its surgical care services are measurable and specific.
Process Currently in Place - Evidence of Current Status
• SPANC-Sunnybrook PeriAnesthesia Nursing Council-involves all nurses within the PeriAnesthesia Departments. Goals included the development of the PeriAnesthesia Handover Tool to improve safety and communication of report at patient transfer through Perianesthesia
• OPANA –increased staff involvement with Professional Association has led to greater understanding of professional and practice Standards
Improvement Strategy / Action Plan
March2010-onward
Continued work around TOA to improve safety-VERBAL TOA IMPLEMENTED

SAQ #30

IS THERE A PROCEDURE TO RECOGNIZE TEAM MEMBERS? YELLOW, LOW PRIORITY
Summary of Related Standard(s) 5.5 The team has a fair and objective process to recognize team members for their contributions.
Process Currently in Place - Evidence of Current Status
• Organizational formal reward program
• Years of service awards
• Nurses week/perianesthesia nurses week
• SPANC blog recognizes accomplishments and introduces new staff
• SPANC offers the opportunity to be involved with change and recognition of group effort
• Letters from patients and families
Improvement Strategy / Action Plan
March2010-onward
Reassess in June

SAQ #29

IS THERE A STAFFING PROCEDURE THAT IS FAIR, TRANSPARENT, AND EVALUATED REGULARLY? YELLOW, LOW PRIORITY
Summary of Related Standard(s) 5.1 The organization has defined criteria that are used to assign team members to clients and other responsibilities in a fair and equitable manner.5.2 Team members have input on work and job design, including the definition of roles and responsibilities, and case assignments, where appropriate.5.3 Team leaders regularly evaluate the effectiveness of staffing and use the information to make improvements.
Process Currently in Place - Evidence of Current Status
• As per ONA contract
• It supports the standards of practice as per CNO and OPANA standards—schedule redesigned to balance shift workload and weekend safety
• TL’s are assigned in every area. This role was developed with staff input
• All members are encouraged to be involved in new initiative or processes as they develop
• Breaks are scheduled with ample RN coverage
Improvement Strategy / Action Plan
March2010-onward
new schedule being implemented

SAQ #28

ARE CLIENTS ABLE TO ACCESS THE TEAM’S SERVICES? YELLOW, LOW PRIORITY
Summary of Related Standard(s) 6.1 The team identifies, and removes , barriers that prevent clients, families, service providers, and referring organizations from accessing services.
Process Currently in Place - Evidence of Current Status
• Multicultural environment with translation services
• Patient flow steering committee with several sub-groups to assist with patient flow issues
• There is an orthopedic task force that deals with the wait and see list
• Beds have been opened to decrease cancellations by developing the SSSU
• There is an increased focus on discharge planning pre-operatively and streamlining ambulatory services
• Revised and redesigned process to increase efficiency in the Pre-Admission Clinic as per the Lean Methodology
• All clients have access to the phlebotomy/ECG/medical imaging areas pre-operatively if tests have been ordered
• Rapid Response Team is available for the Surgical Short Stay Unit, should their services be required
• OT and PT sees the breast patients in the SSSU for post-op teaching
• CCAC also involved with SSSU-dressing packages are available for patients to take home
Improvement Strategy / Action Plan
March2010-onward
Reassess in June

SAQ #27

DOES THE TEAM HAVE THE RESOURCES AND SUPPORTS NEEDED TO ACHIEVE ITS GOALS AND OBJECTIVES? YELLOW, LOW PRIORITY
Summary of Related Standard(s)
2.3 The team identifies the resources needed to achieve goals and objectives.2.4 The team has access to the supplies and equipment needed to deliver surgical care services.2.5 The organization provides support to the team to deliver quality surgical care services.
Process Currently in Place - Evidence of Current Status
• SPANC-Sunnybrook PeriAnesthesia Nursing Council-involves all nurses within the PeriAnesthesia Departments. Goals included the development of the PeriAnesthesia Handover Tool to improve safety and communication of report at patient transfer through Perianesthesia
• OPANA –increased staff involvement with Professional Association has led to greater understanding of professional Standards
• Learning and development opportunities are provided through Organizational Development workshops, monthly inservices and staff meetings, educational days ie PEP day, recertification day, conferences, SPANC meetings and Blog
• Patient information materials have been developed for PAC and Day of Surgery with written instructions given to patients to ensure they understand pre-op information
• Policies and procedures are available to staff on-line
• Manager/educator support available
• Equipment and supplies are available on all units and replenished daily
Improvement Strategy / Action Plan
March2010-onward
Reassess in June

SAQ #26

HOW DOES THE TEAM USE THE INFORMATION IT COLLECTS ABOUT THE QUALITY OF ITS SERVICES? YELLOW, HIGH PRIORITY
Summary of Related Standard(s)
16.3 The team compares its results with other similar interventions, programs, or organizations.16.4 The team uses the information it collects about the quality of its services to identify successes and opportunities for improvement, and makes improvements in a timely way.16.5 The team shares evaluation results with staff, clients, and families.
Process Currently in Place - Evidence of Current Status
. We have perianesthesia contacts at other facilities through OPANA networking. Ideas and questions are shared and if applicable are further shared with staff.
. Picker scores
Improvement Strategy / Action Plan
March2010-onward
Reassess in June

SAQ #25

ARE THERE PROCEDURES TO IMPROVE HOW THE TEAM WITH DIFFERENT PROFESSIONALS WORK TOGETHER? YELLOW, HIGH PRIORITY
Summary of Related Standard(s)
3.3 The organization encourages all team members to develop skills to improve the interdisciplinary approach and team functioning.3.4 The team develops standardized processes and procedures to improve teamwork and minimize duplication.3.5 The organization provides workspace to support interdisciplinary team functioning and interaction.3.6 The interdisciplinary team communicates regularly to coordinate services, roles, and responsibilities.3.7 The interdisciplinary team follows a formal process to regularly evaluate its functioning, identify priorities for action, and make improvements.
Process Currently in Place - Evidence of Current Status
• Unit council has been reestablished to include all of the PeriAnesthesia departments.
• PEP day includes the OR, PeriAnesthesia as well as members from the Holland Site
• With the Regional Block area program, AA’s and Anesthesia work with the RN in a pre-op environment
• Group education sessions: inservices with surgeon, anesthesia involvement
• OR and Support services quality and operations committee includes membership from PeriAnesthesia, B6 clinics, OR and Holland Centre. Includes Director, 4xPCMs, 3xCE’s ,AA’s, perfusionists
• Consistent Team Leaders provide continuity
Improvement Strategy / Action Plan
November 2009 - February 2010
1. PACU TL is Sheryl 1 yr
2.Unit based council needs assistance: difficulty finding staff who will volunteer their time. Need to recruit. Lan and Sandi are the co-chairs and attend corporate nursing council and then relay information to staff.
March2010-onward
Ongoing need to have consistent interest from staff in attending unit coucil

SAQ #24

HOW DOES THE TEAM RESPOND TO PEOPLE WHO ASK FOR SERVICES OR INFORMATION? YELLOW, HIGH PRIORITY
Summary of Related Standard(s)
6.3 The team responds in a timely way to requests for services and information. 6.4 The team gives potential clients, families, providers, and referring organizations information about the organization and its services.
Process Currently in Place - Evidence of Current Status
• OPANA Board of Director reps share information with other groups regarding current practices
• Pamphlet and booklets redesigned for PAC and also for SSSU
• PACU visitor policy
• Pre-op classes available in PAC
• Pre-op teaching in PAC and SDS
• Post-op/discharge teaching in SDS and SSSU
• f/u call made by SSSU nurses within 48 hours of discharge
• physicians are available via SMART page during business hours
Improvement Strategy / Action Plan
November 2009 - February 2010
1. Planning information kiosks for PAC
2. update pamphlets for specific surgeries in PAC and SDS/SSSU
March2010-onward
Late career initiate nurses working on pamphlets

SAQ #23

IS THERE A PROCESS FOR IDENTIFYING AND REDUCING RISKS TO TEAM MEMBERS DELIVERING SURGICAL CARE SERVICES? YELLOW, HIGH PRIORITY
Summary of Related Standard(s)
5.4 The team has a process for identifying and reducing risks to team members while delivering surgical care services..
Process Currently in Place - Evidence of Current Status
• Schedule was redesigned for 2 RN coverage at all times: minimal staffing guidelines as per standards
• Staff are encouraged and reinforced to use e-safety reports for near misses, bullying, actual events, sentinel events
• IPAC rep available and does regular rounds
• Hand hygiene training
• ARO/MRSA screening in PAC with f/u in SDS and PACU
• Violence prevention: unit has ID badge scan entry after hours
• Panic buttons available
• Emergency call system in place
• Safety walkabouts with senior leadership
• Safety committee: staff regularly inspect the workplace environment to identify existing/potential concerns and report to manager, or send broken equipment to biomedical engineering
• Hand hygiene products are located at POC
• Occupational Health and Safety available for staff when ill, or returning to work after extended leave
• WHIMIS, fire and safety, back safety, violence prevention programmes etc available through education days or through e-learning
Improvement Strategy / Action Plan
November 2009 - February 2010
PACU least restraint algorithm indicates issues surrounding Emergence Delerium
March2010-onward
Ongoing

SAQ #22

HOW DOES THE TEAM HANDLE CLIENT RIGHTS, COMPLAINTS, AND ETHICS ISSUES? YELLOW, HIGH PRIORITY
Summary of Related Standard(s):
8.8 The team provides clients and families with access to emotional support and counseling. 8.9 The team educates clients and families about their rights, and investigates and resolves any claims that these rights have been violated.8.10 The team follows the organization’s process to identify, address, and record all ethics-related issues.
Process Currently in Place - Evidence of Current Status
• Patient advocacy promoted
• RN’s and physicians listen to patients when they voice their concerns
• We have implemented a cancellation kit with a follow up letter from Dr. Keith Rose being edited
• Ongoing educational information regarding potential ethical issues such elder abuse, violence in the workplace, bullying
• Staff follows the process to escalate patients’ concerns. Manager is available Mon-Fri and a shift manager is available after hours to deal with client/family concerns.
. In-services are provided to staff when necessary
• If further assistance is required, patient advocacy office is available for client and family concerns.
Improvement Strategy / Action Plan
July 2009-Oct 2009
in-service PACU regarding Least Restraint/Consent to Treament/Deirium in Oct
November 2009 - February 2010
Hospital initiative re least restraint- policy being updated
Developing an algorithm for PACU re: least restraint
March2010-onward
Ongoing project

SAQ #21

HOW DOES THE TEAM MAKE SURE CLIENTS AND FAMILIES ARE PREPARED FOR THE END OF SERVICES? YELLOW, HIGH PRIORITY
Summary of Related Standard(s):
11.1 The team tells clients and families what to expect during transition or end of service.11.2 The team works with other teams, services, and organizations to determine the client’s placement and develop a follow-up plan. 11.3 The team provides the client, family, or caregiver with instructions for post-procedure care and the possible consequences of failing to follow the instructions. 11.5 REQUIRED ORGANIZATIONAL PRACTICE: The team transfers information effectively among service providers at transition points.11.6 Following transition or end of service, the team contacts clients, families, or referral organizations or teams to evaluate the transition, and uses this information to improve its transition and end of service planning.
Process Currently in Place - Evidence of Current Status
• Discharge planning is started in PAC and instructions for discharge are given as accurately as possible. (Sometimes patients discharge plans change intra or post op)
• PAC initiates CCAC, SW
• During PAC appointment, pt’s post-op needs are assessed by anesthesia to ensure that the surgeon has requested the most appropriate level of care for patient post-operatively.
• Ambulatory patients are requested to have a responsible adult drive them home and stay with them for the first night post-operatively. This information is given in PAC appointment, on day of surgery, and again post-operatively. It is included in the booklet "My surgical Journey” and on the back of the Consent form there is also a signature required from the patient or SDM that they understand this information.
• SSSU patients are aware that they are to be discharged before 9am on POD #1. Information is given to them by surgeon, in PAC appointment, and again in SSSU. Discharge orders must be on the patients chart by the time patient leaves PACU.
• Written materials are given upon discharge and verbal discharge teaching is done to patient and family members
• The SSSU provides courtesy telephone call-backs to ensure that patient pain control is adequate.
-Patient Flow is working on determining Standard Length of Stay.
The new BMS will also assist in identifying possible discharges/discharge times.
Improvement Strategy / Action Plan
July 2009-Oct 2009
PAC information pamphlet and 'My Surgical Journey' booklet printed and available.
PAC pamphlet is dispersed in the Surgeon’s office to prepare patients for their PAC appt.
My Surgical Journey booklet is given to the patient at their PC appointment.
November 2009 - February 2010
Patients having a telephone appt only, or who have their PAC appointment elsewhere are mailed their booklet with instructions. Surgical care pathways to be designed for SSSU patients
March2010-onward
Ongoing project

SAQ #20

WHAT KINDS OF EDUCATION, SUPPORT, AND COUNSELLING ARE AVAILABLE FOR CLIENTS AND FAMILIES? YELLOW, HIGH PRIORITY
Summary of Related Standard(s): 8.7 The team provides clients and families with education related to service needs. 8.8 The team provides clients and families with access to emotional support and counseling.
Process Currently in Place - Evidence of Current Status
• Patient Focused Care model
• Pre and post op teaching is done
• Accessibility to Social work, chaplain, physio and occupational health as required
Improvement Strategy / Action Plan
November 2009 - February 2010
1. Would like to have PAC information available on the internet for patients to access
2. Development of a video that could be played in the PAC waiting room with pre-and post op info
March2010-onward
Ongoing project with late career nurses

SAQ #19

WHAT IS INCLUDED IN THE CLIENT’S PRE-OPERATIVE ASSESSMENT? GREEN FLAG, LOW PRIORITY
Summary of Related Standard(s): 7.3 The team assesses the client’s physical and psychosocial health.7.7 The pre-procedure assessment includes processes to evaluate the client’s post-procedure pain.7.8 The pre-operative assessment includes processes to evaluate the client’s post-operative
Process Currently in Place - Evidence of Current Status
• Surgeon H & P and anesthesia questionnaire
• Medical hx, health status, nutrition status, mental health
• ARO/MRSA
• Medication reconciliation form
• Allergies
• Labwork
• ECG
• Other tests as applicable
• PONV assessed by anesthesia
• Handover tool started in PAC to increase communication amongst health care providers
Improvement Strategy / Action Plan
November 2009 - February 2010
moving towards increasing the number of nurse-only pre-admission assessments
March2010-onward
Ongoing project-anticipated pt increase of 800-1200 with Women’s program moving to SB campus

SAQ #18

DOES THE TEAM CONDUCT A PRE-OPERATIVE ASSESSMENT? GREEN FLAG, LOW PRIORITY
Summary of Related Standard(s): 7.2 The team completes a timely pre-operative assessment for each client. 7.4 The team considers the client’s needs and expectations, family and caregiver involvement, and staffing resources during the assessment process.7.5 The team has access to diagnostic services, results, and expert consultation to complete a proper pre-operative assessment.
7.13 The team has a process for forwarding the information obtained from the pre-operative assessment and admissions process to service providers in the operating room.
Process Currently in Place - Evidence of Current Status
• PAC redesign plans includes ALL patient screening including all previous known ‘healthy’ patients (optha, gyne, plastics)
• Assess family support systems is part of the assessment
• CCAC, SW,PT, OT consulted
• Scheduled pre-op classes for ACL and Breast, and cardiac patients
Improvement Strategy / Action Plan
November 2009 - February 2010
PACU nurse/telephone triage tool March2010-onward
Ongoing project

SAQ #17

DOES THE TEAM USE A PROCEDURE-SPECIFIC CARE MAP? GREEN FLAG, LOW PRIORITY
Summary of Related Standard(s): 7.1 the team uses a procedure-specific care map to guide the client through preparation for and recovery from the procedure.
Process Currently in Place - Evidence of Current Status
• SSI (Surgical Site Infection) procedures with the cardiac and general surgery groups to provide best practice and evidence based practice pre- and intra- op
• Surgery specific pre and post-op standard printed orders
• Pre-op screening tool in PAC
• Spinal care pathway for SSSU patients transferring to Holland Centre
• Discharge criteria in PACU and OPP
• SSSU admission and discharge criteria’s
Improvement Strategy / Action Plan
November 2009 - February 2010
1. Develop surgery specific care plans
2. Develop standardized doctor's orders for PACU
March2010-onward
Ongoing project

SAQ #16

DOES THE TEAM UNDERSTAND AND FOLLOW POLICIES TO PREVENT AND CONTROL INFECTIONS? GREEN FLAG, HIGH PRIORITY
Summary of Related Standard(s): 5.1 The organization develops an IPAC education program that is tailored to the organization, its services, and client populations. 5.2 The IPAC education program specifies each staff member’s/service provider’s/volunteer’s role in preventing/controlling infections. 5.3 The IPAC education program covers personal precautions and high-risk activities performed in the organization.5.4 Staff, service providers, and volunteers attend the IPAC education program at orientation and regularly.5.6 The organization provides its staff, service providers, and volunteers with access to IPAC education materials, resources, information, and tools.5.7 The organization monitors compliance with its infection prevention, control policies and procedures.
Process Currently in Place - Evidence of Current Status
• PACU 1:1 with ARO positive patients. Designated equipment and PPE worn. Curtains define patient area and ESP’s and PSP’s are specially trained for environmental cleaning
• Fit mask testing for N95 masks for all staff
• ARO testing is initiated in PAC and followed through the process
• IP&C P&P’s available on-line
• Q2yr certification for PPE application
• Hand hygiene retreat with IP&C involvement to occur in May
• PeriAnesthesia SSI committee members for both CV and Gen surg. Keep staff up-to-date on new initiatives
• Universal precautions are also adhered to
Improvement Strategy / Action Plan
November 2009 - February 2010
1. IPAC RN's invited to Staff meetings to talk about MRSA precautions in the perianesthesia environment with no definite isolation rooms
2. inservice also discussed how Eating and drinking in patient care areas is not permitted by staff or visitors
March 2010 – onward
Follow up with staff