SAQ #49

DO THE TEAM’S RESEARCH ACTIVITIES MEET RESEARCH AND ETHICS REQUIREMENTS? GREEN, HIGH

SUMMARY OF RELATED STANDARD(S) 14.4 The team’s research activities for surgical care services meet applicable research and ethics protocols and standards.

Process Currently in Place - Evidence of Current Status
• All approved research projects must follow P&P including ethics committee approval

Improvement Strategy / Action Plan
Reassess in June

SAQ #48

DOES THE TEAM DISCUSS ORGAN DONATION WITH THE CLIENT? RED, HIGH

SUMMARY OF RELATED STANDARD(S) 8.5 Prior to a procedure, the team discusses organ donation with the client, and provides an opportunity for the client to consent to organ donation

Process Currently in Place - Evidence of Current Status
Unless Sunnybrook has a policy outside the ICU-ER that states otherwise, TGLN would only expect a call at end-of-life from the other units when it is family initiated, as we have not designated these units to report all deaths or to approach families.
You can order hard copies of these FAQs through Woodlands to place on the units. The PDF file can be used on the hospital intranet if available.
Below is the information that we have provided to other hospitals who have asked us about surgical accreditation standards of consenting patients.
What is the TGLN policy about discussion organ and tissue donation?
We only approach families in end of life situations and so our policies and procedures are related to this work in hospitals. None of our procedures or guidelines contemplate the situation the surgical standard is proposing. Where we do have a position in speaking with ‘healthy’ Ontarians’ is through our communication strategy that is targeted to Ontario Citizens and promotes registration of consent at OHIP offices.
What are other hospitals in the province doing?
In checking with our coordinators across the province we have identified that three hospitals are currently asking a question about donation at the point of admission. An additional three hospitals have discussed whether they would ask a question about donation preference but have not implemented one as yet. They are questioning the appropriateness of asking this question to patients coming for care. They are concerned about untrained staff asking this question and perceptions of the public that they will not be treated or questioning the hospitals standard of care. *See also PDF sent from GTL

Improvement Strategy / Action Plan
Reassess in June

SAQ #47

IS THERE A TEAM WITH DIFFERENT PROFESSIONALS WITH CLEAR ROLES AND RESPONSIBILITIES? GREEN, LOW

SUMMARY OF RELATED STANDARD(S) 3.1 The organization identifies an interdisciplinary team to deliver surgical care services.13.2 Team members receive education and training on information systems and other technology

Process Currently in Place - Evidence of Current Status
• Nurses, patient service partners, environmental service providers, patient administrative assistants work together in PAC, SDS, PACU and SSSU. Each have defined roles and responsibilities but work together collaboratively to meet patient and family requirements
• Anesthesia care team involves anesthesiologists, Anesthesia Assistants, Respiratory Therapists, Nurse Practioners and Acute Pain Service

Improvement Strategy / Action Plan
Reassess in June

SAQ #46

IS THERE A COMMITMENT TO ONGOING LEARNING IN THE SURGICAL CARE TEAM? GREEN, LOW

SUMMARY OF RELATED STANDARD(S) 1.4 The team collaborates with other services, programs, providers and organizations to identify, address, and coordinate services across the continuum of care.

Process Currently in Place - Evidence of Current Status
• PAC redesign includes increased involvement with CCAC
• service specific discharge planning groups ie: orthopedics,
• breast patients are linked with the Odette Centre
• updated PAC pamphlet and Day of Surgery Booklet

Improvement Strategy / Action Plan
1. goal is to have information on web by end of April
2. CCAC inservice for SSSU

SAQ #45

IS THERE A COMMITMENT TO ONGOING LEARNING IN THE SURGICAL CARE TEAM? GREEN, LOW

SUMMARY OF RELATED STANDARD(S) 4.5 The team receives specific education and training to deliver surgical care services.4.6 The team supports student and volunteer placement on the surgical care team.4.7 The team monitors and meets each team member’s ongoing education, training, and development needs.

Process Currently in Place - Evidence of Current Status
• Staff meetings and inservices-interdisciplinary speakers are invited
• Education days , Recert
• Conference support OPANA, NAPAN, Oncology day
• Staff encouraged to join professional association (OPANA)
• Summer students and co-op volunteers
• Nurse Champions Block areas
• Increased hospital awareness of PeriAnesthesia process ie: tours, shadow days
• SSSU development and expansions
• PAC redesign and pamphlet development
• Regular Email updates
• Regular Blog information updates

Improvement Strategy / Action Plan
• P&P development
PEP day in May

SAQ #44

DOES THE TEAM SHARE RESEARCH AND BENCHMARK INFORMATION AGAINST OTHER ORGANIZATIONS? GREEN, LOW

SUMMARY OF RELATED STANDARD(S) 14.5 The team shares benchmark and best practice information with its partners and other organizations.

Process Currently in Place - Evidence of Current Status
• Inservices and educational opportunities such as journal articles
• Strategic Balanced Scorecard
. OR data office statistics are gathered and benchmarked to ensure we meet obligations, wait times, cancellations and number of funded cases
• Reflective practice

Improvement Strategy / Action Plan
Reassess in June

SAQ #43

ARE TEAM MEMBERS’ COMPETENCY AND PERFORMANCE REGULARLY CHECKED? GREEN, LOW

SUMMARY OF RELATED STANDARD(S) 4.1 Each team member has the necessary credentials or license from the professional college.4.8 Team leaders regularly evaluate and document each team member’s performance in an objective, interactive, and positive way.

Process Currently in Place - Evidence of Current Status
• Yearly license registration through CNO
• CPR recertification q2yrs
• ACLS q2 yrs recommended
• Orientation performance evalutation tool is used to evaluate performance in the areas of safety in practice, skills and procedures, critical thinking, communication, documentation etc
• Recertification q2yrs for Advanced Nursing Competencies, held on recert day
• Hospital recertifications can be done through e-learning, specific WHIMIS days, and on PEP day.
• Inservices provided on new equipment such as ICP EVD’s, 12 lead monitor, Lifepac 20, neoteric OR blood fridge
• Reflective practice

Improvement Strategy / Action Plan
• Performance evaluations

SAQ #42

HOW DOES THE TEAM DECIDE WHICH GUIDELINES IT WILL USE? GREEN, LOW
SUMMARY OF RELATED STANDARD(S) 14.1 The organization has a process to select evidence-based guidelines for surgical care services.14.2 The team reviews guidelines to make sure they are up-to-date and reflect current research and best practice information.14.3 The team’s guideline review process includes seeking input from staff and service providers about the applicability/ease to use of the guidelines

Process Currently in Place - Evidence of Current Status
• College of Nurses
• Ontario PeriAnesthesia Nurses Association
• National Association of PeriAnesthesia Nurses
• Surgical Site Infection Best Practice guidleines for Gen surg and Cardiac groups directly affects SDS pre-op area: clipping, pre-warming, IP&C,
• Pre-and post-op Acute Pain Service guidelines
• Discharge criteria/guidelines P&P for PACU, SDS, SSSU

Improvement Strategy / Action Plan
Reassess in June

SAQ #41

ARE CLIENT RECORDS KEPT UP-TO-DATE AND SECURE? GREEN, LOW

SUMMARY OF RELATED STANDARD(S) 12.1 The team maintains an accurate and up-to-date record for each client. 12.2 The team meets applicable legislation for protecting the privacy and confidentiality of client information.12.3 Clients have opportunities to access their records.

Process Currently in Place - Evidence of Current Status
• The team follows SHSC on-line P&P on Privacy and Security of Personal Health Information
• ‘My Chart’ is available for pt access on the Sunnybrook internet site
• Charts are locked in secure areas overnight

Improvement Strategy / Action Plan
Reassess in June

SAQ #40

DOES THE TEAM HAVE ACCESS TO CLIENT INFORMATION NEEDED TO DO THE WORK? GREEN, LOW

SUMMARY OF RELATED STANDARD(S) 12.4 Staff and service providers have timely access to the client record.12.5 The team shares client information and coordinates its flow among service providers, other teams, and other organizations, as required.

Process Currently in Place - Evidence of Current Status
• Handover Tool within perianesthesia department
• Pt’s current and previous chart
• EPR
Improvement Strategy / Action Plan
Reassess in June

SAQ #39

DOES THE TEAM CONDUCT AN ADMISSION PROCESS? GREEN, LOW

SUMMARY OF RELATED STANDARD(S) 7.9 The team conducts a comprehensive admission process for clients undergoing surgical or other invasive procedures.

Process Currently in Place - Evidence of Current Status
• Registration confirms 2 pieces of ID, Bradma and ID armband are correct
• Or checklist confirms information between the RN and the Patient
• Charts are checked 1 day pre-op and on pt arrival to SDS to ensure pre-op orders have been followed, including diabetic protocols, SSI protocols
• Consent is verified for accuracy with patient
Improvement Strategy / Action Plan
Opthalmology working group

SAQ #38

HOW DOES THE TEAM DETERMINE WHETHER TO PROVIDE SERVICES TO THE CLIENT? GREEN, LOW
SUMMARY OF RELATED STANDARD(S) 6.5 With the client’s permission, the team gathers health history information to determine the need for service.

Process Currently in Place - Evidence of Current Status
• PAC screening requires a surgeon’s history and physical
• Pt must answer the anesthetic questionnaire which the PAC nurse then assesses. From there, the patient may require a telephone only appointment, an office appointment with the RN, RN-GP, RN-anesthesia, depending on patients comorbidities
• PAC appointment and assessment to determine fitness for surgery. If at high risk, bed allocation to the ICU’s may be arranged pre-op. Also patients identified as appropriate for SSSU admissions are assessed as per criteria in policy
• Ongoing assessments throughout all phases of PeriAnesthesia by RN’s
• Diabetic patient require the services of Diabetic APN prior to returning home on the day of surgery so that they are aware of their insulin needs
Improvement Strategy / Action Plan
Reassess in June

SAQ #37

DOES THE TEAM HAVE A STANDARDIZED PROCESS FOR PRIORITIZING AND SCHEDULING ELECTIVE PROCEDURES? GREEN, LOW
SUMMARY OF RELATED STANDARD(S) 6.7 The team uses a standardized process to prioritize and schedule elective procedures.

Process Currently in Place - Evidence of Current Status
• Done through the OR booking office and supported by OR booking policies.
• Diabetic patients are usually booked as first case of the day
Improvement Strategy / Action Plan
Reassess in June

SAQ #36

DOES THE TEAM PROVIDE CLIENTS WITH INSTRUCTIONS ON HOW TO PREPARE FOR THE PROCEDURE? GREEN, LOW
SUMMARY OF RELATED STANDARD(S) 7.6 The team provides the client with instructions on how to prepare for the procedure, and outlines possible consequences of failing to follow the instructions.
Process Currently in Place - Evidence of Current Status
• Pre-and post-op onsite teaching in PAC
• Odette Centre has primary RN’s and APN’s who do comprehensive teaching
• Updated PAC pamphlet given to patient at surgeon’s office visit to prepare them for their PAC appointment
• “Day of Surgery” booklet given to patients at their PAC appointment with written instructions along with verbal instructions
• A family member who speaks English is encouraged to come to PAC/SDS with patient for emotional support, as well as educational support
Improvement Strategy / Action Plan
1. update surgical information in PAC-ongoing