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

SAQ #15

HOW DOES THE TEAM IDENTIFY, REPORT, AND MANAGE INFECTIONS? YELLOW, HIGH
Summary of Related Standard(s) 9.1 The organization has a process to detect suspected healthcare-associated infections 9.2 The process identifies who is responsible and what the reporting relationships are for infection prevention and control issues. 9.4 The organization has policies and procedures to contain and prevent the spread of infectious agents, including ventilation, isolation and other precautions, and cohorting as necessary.
Process Currently in Place - Evidence of Current Status
• ARO & respiratory screening is done in PAC. PAC follows isolation precautions if pt is known MRSA
• Results are followed up, the OR is informed, it is noted on OR schedule. EPR is checked the night before by the PAA in SDS and PACU to double check ARO status of all patients
• Isolation precautions are followed as soon as a patient is admitted to SDS pre-operatively and information is communicated on the handover tool
• Isolation precautions are followed post-operatively in PACU, SDS. At this time, MRSA and Isolated patients do not meet the admission criteria for the SSSU, as per IPAC the curtains no longer meet isolation criteria after 12 hours
• On-line P&P IP&C standards are followed
• If there is a break in communication, or a pt has not been identified in a timely manner, an e-safety report is filed and IP&C is informed immediately.
• Pt with identified isolation precautions will only be admitted to an isolation room once transferred out of PACU
· the bed management system will flag ARO's
· -manager and educator attend monthly Gen surg and Cardiac SSI meetings and relay information back to staff. Inservices have been held regarding pre-warming Gen surg patients in SDS, and correct clipping method for cardiac patients, as well as mouth care.
· All Patients are instructed by PAC to take chlorhexidine showers for 3 days prior to their surgical date
· Braden Skin Risk documentation is started in PAC
· Mandatory Hand Hygiene classes for all staff. ABHR strategically located and signs posted to encourage staff and visitors to comply with HH.
· all staff required to be N95 fit-tested q 2 yrs, as well, are req'd to pass IPAC PPE class q2
· Self surveillance for ARO: healthy workplace environment promoted.
· Flu clinics also available yearly by Occ Health
· Visitors are also requested to abstain from visiting if they are unwell. 1 visitor per patient is encouraged: visitor policy in effect.
· No food or drink at bedside, for staff and visitors.
· no hand or wrist jewelry when providing direct patient care


Improvement Strategy / Action Plan
July 2009-October 2009
1.PeriAnesthesia Handover Tool being utilized well.
2. IPAC RN's have attended staff meetings and education days to assist with education regarding PPE and HH
November 2009 - February 2010
1. Currently there are some MRSA in-patients who go to the OR, and then isolation requirements are not relayed to the PACU staff. The BMS is being introduced Nov 17 this will identify ARO flags. There are identified super users in each unit who will help the other staff learn the system
2. Hospital committee on Transfer of Accountability working on standardized SBAR tool between units. This will help also help identify ARO positive patients. TOA to be rolled out in January 2010.
3. Braden Skin Risk documentation needs to be completed in PACU will require inservicing on the importance of this tool
March 2010 - onward
1. Reassess to see if the BMS is identifying all ARO patients
2. Reassess to see how the TOA guide is working at identifying ARO pts at handover
3. Reassess to see if PACU is completing the BSR doc

SAQ #14

DOES THE TEAM EDUCATE CLIENTS AND FAMILIES ABOUT PREVENTING INFECTIONS? GREEN, HIGH
Summary of Related Standard(s) 7.1 The organization provides clients and families with information and education about preventing infections .7.2 The information and education provided to clients and families about IPAC covers hand hygiene and respiratory etiquette 7.3 Information provided to clients and families is documented in the client record.7.4 Families and visitors have access to hand hygiene resources and personal protective equipment if necessary.7.5 Staff, service providers, and volunteers encourage clients, families, and visitors to follow effective hand hygiene behaviour.
Process Currently in Place - Evidence of Current Status
• PAC provides chlorhexidine soap to pts with pre-op instructions.
• Staff educates families and patients on HH and PPE when needed
• Hand hygiene posters and sanitizer available at POC and upon entrance to hospital and units
Improvement Strategy / Action Plan
Reassess in June

SAQ #13

DOES THE TEAM EDUCATE CLIENTS AND FAMILIES ABOUT THEIR ROLE IN PROMOTING SAFETY? YELLOW, HIGH
Summary of Related Standard(s) 15.3 REQUIRED ORGANIZATIONAL PRACTICE: The team educates its clients and families in writing/verbally about the client and family’s role in promoting safety.
Process Currently in Place - Evidence of Current Status
• There is a patient handbook available in PAC
• Patients and families are given verbal information regarding Hand Hygiene and PPE
• Written materials complements verbal information regarding discharge instructions
• Availability of a responsible adult to drive a patient home and care for the pt for the first post-op night is a condition of discharge from OPP. Pt’s sign an agreement, this is for their safety.
• Patients and their family and friends are instructed that the patient should be the only person pushing the PCA button
Improvement Strategy / Action Plan
Nov-Feb
1. Signs on doors to SDS indicating no food or drinks
2. ABHR on walls at every entrance, as well as notices regarding signs and symptoms of flu

SAQ #12

HOW DOES THE TEAM HANDLE SENTINEL EVENTS, NEAR MISSES, AND ADVERSE EVENTS? YELLOW, HIGH
Summary of Related Standard(s) 15.5 The team identifies, reports, records, and monitors sentinel events, near misses, and adverse events.15.6 The team follows the organization’s policy and process to disclose adverse events to clients and families.
Process Currently in Place - Evidence of Current Status
• E-safety reports
• No blame culture encourages staff to file reports
• Quality and Risk Management will f/u with patient/family for an adverse/sentinel event
• Staff debriefing sessions after adverse events
• Development of the PeriAnesthesia Handover tool
Improvement Strategy / Action Plan
Reassess in June

SAQ #11

HOW ARE MEDICATION ERRORS AND INCIDENTS HANDLED BY THE TEAM? YELLOW, HIGH
Summary of Related Standard(s) 10.7 The team documents all incidents involving medications, and uses this information to make improvements.
Process Currently in Place - Evidence of Current Status
• E-safety reports are filed as soon as possible for near misses and adverse events. They are also trended.
• MD informed if necessary
• No blame policy
Improvement Strategy / Action Plan
E-safety reporting changes were relayed to staff.
The changes should make the reporting more user-friendly.

SAQ#10

HOW ARE MEDICATIONS MANAGED IN THE SURGICAL CARE AREA? GREEN, HIGH
Summary of Related Standard(s) 10.1 The team identifies who is responsible for prescribing/storing/handling/and disposing of medications, as well as recording medication information in the client record.10.6 The team follows the organization’s policies on storing/ disposing of medications safely and securely.10.2 Before dispensing medication, a qualified team member reviews each prescription for completeness/accuracy.10.3 A qualified team member fills the prescription and dispenses the medication in a timely/accurate way.10.4 The team responds to requests for medication and medication information after hours and in emergencies.10.5 The team has a process to evaluate client requests to bring in or self-administer their own medication.

Process Currently in Place - Evidence of Current Status
• N/A in PAC, other than Patient Medication Record and Allergy record initiated
• PACU, SDS and SSSU follow specific pre and post op orders
• College Of Nurses standards of practice guidelines are followed
• Night cupboard is available to access necessary medications
• Medication fridges
• Narcotic cupboard with regular scheduled counts
• McKessin narcotic cart will be implemented in near future
• Regular stocked drugs in all areas dependant on the need
• Emergency medication trays available on arrest cart
• Designated pharmacist
• Independent Double check for heparin and insulin, PCA's and Epidurals

Improvement Strategy / Action Plan
Jan 2010-March2010
1. McKessin cabinets now implemented and staff using them as narcotic cupboard
2. symbiq pumps implemented in all areas infusing medications

SAQ#9

IS HAND HYGIENE IMPORTANT TO THE TEAM? GREEN, HIGH

Summary of Related Standard(s) 6.1 REQUIRED ORGANIZATIONAL PRACTICE: The organization delivers education and training for staff/service providers/and volunteers on hand hygiene.6.4 The organization’s staff, service providers and volunteers have access to alcohol-based hand rubs at the point-of-care and service delivery.6.5 REQUIRED ORGANIZATIONAL PRACTICE: The organization evaluates compliance with hand hygiene practices.

Process Currently in Place - Evidence of Current Status
• HH session on PEP day May 8th with goal to achieve 100% compliance
• Hand hygiene audits have been done by IP&C
• HH e-learning module
• Waterless, alcohol based hand rub at every unit entrance, work station, bedside. POC
• HH posters at strategic locations
• P&P on intranet

Improvement Strategy / Action Plan
July 2009-ongoing
1. ongoing auditing by OHS
2. staff awareness of compliance percentages

SAQ#8

IS THERE A TEAM FOCUS ON IMPROVING SAFETY? YELLOW, HIGH
Summary of Related Standard(s) 15.1 The team is trained to identify, reduce, and manage safety risks 15.2 Staff and service providers participate in regular safety briefings to share information about potential safety problems, reduce the risk of error, and improve the quality of service

Process Currently in Place - Evidence of Current Status
• Safety Walkabouts done by senior leadership identify key issues to be addressed in PACU and SDS
• E-safety reporting: trends are shared with staff
• Inservices regarding issues and practices (also posted on Blog)
• WHIMS and Fire Safety
• Code Orange simulation exercise and pandemic planning
• E-learning modules

Improvement Strategy / Action Plan
Nov 2009-ongoing: review in February
1. Shelly and Dale represent PACU Safety Committee
2. Stania and Pam have volunteered to be Mground Reps for Safety committee

SAQ#7

HOW DOES THE TEAM CARE FOR THE CLIENT FOLLOWING THE PROCEDURE? GREEN, HIGH
Summary of Related Standard(s) 9.1 One or more designated team members observe the client during the transfer from the operating room to the Post-Anesthesia Care Unit (PACU).9.2 the team continues to monitor and provide bedside care to clients as they recover from anaesthetic.9.3 the team applies standardized criteria when determining whether a client is fit for discharge

Process Currently in Place - Evidence of Current Status
• Anesthesiologist and OR nurse transfer patient from the OR to PACU and report is received from Anesthesiologist
• PACU staff have critical care training and in-depth orientation to the PACU patient
• A new handover tool provides a concise and comprehensive report about the client’s surgical journey. This includes PAC/SDS med-surg history, operation and highlights and a PACU report to phase 2 recovery areas
• Verbal report PRN
• Opthalmology patients return direct to SDS post-op, if there are concerns, report is given by Anesthesia Assistant or the OR nurse.
• Emergency and crash cart available
• PACU staffed 1:2 nurse: patient ration unless patient requirement dictates otherwise ie: critical care vented pt, isolated patient
• SDS staffed 1:3-5 nurse: patient ratio as per OPANA guidelines
• Aldrete scoring system is utilized and part of the PACU discharge policy
• PADDS scoring system is part of the SDS policy
• Pain number scoring system is used throughout PeriAnesthesia departments
• PONV reported in documentation and on Handover. Pain flow sheet has an algorithm in dealing with this issue for patients on PCA/Epidural infusions

Improvement Strategy / Action Plan
Nov 2009-June 2010
1. Ophthalmology task force
2. Develop care pathways for SDS and SSSU for newer procedures

SAQ #6

DOES THE TEAM RECONCILE THE CLIENT’S MEDICATIONS AT TRANSITION OR END OF SERVICE? YELLOW, HIGH
Summary of Related Standard(s): 11.4 REQUIRED ORGANIZATIONAL PRACTICE: The team reconciles medications with the client at referral or transfer, and communicates information about the client’s medications to the next provider of service within or outside the organization.

Process Currently in Place - Evidence of Current Status
• Reconciliation in PAC on 'Medication Record'
• Pamphlet instructs patient to bring meds in pre-op
-in SDS pre-op the pt is asked if there has been any changes in their meds since their PAC appt, and also which meds they took on the morning of their surgery date
-medications are also listed by the pt on the anesthetic questionnaire
• OPP and SSSU patients are instructed on use of newly ordered meds and when to resume pre- op meds and pt's are sent home with a prescription
· PACU checks post-op surgeons orders

Improvement Strategy / Action Plan
Nov 2009-Feb 2010
1. PACU to complete MAR for patients staying overnight

SAQ #5

DOES THE ANAESTHETIST CONDUCT A PRE-ANAESTHETIC ASSESSMENT? YELLOW, HIGH
Summary of Related Standard(s) 7.12 the anaesthetist conducts a pre-anaesthetic assessment prior to the commencement of the procedure.
Process Currently in Place - Evidence of Current Status
· In PAC patients are triaged by the nurse into appointment type. Ie: telephone consult by nurse, PAC appt with nurse, PAC appt with nurse and GP, PAC appt with nurse and anesthetist
· Pre-op, anesthesia does an assessment in the OR holding area/induction room/Block area
· In -patients who are having surgery are s/b the anesthesia resident on-call the night before
· in the ED, pt's are assessed by anesthesia if surgery is required.
Improvement Strategy / Action Plan
July 2009-October 2009
Due to the Schulich construction, holding area no longer available pre-op, however anesthesia still conducting pre-anesthetic assessment outside OR room Reassess process in February
Jan 2010-March2010
Implementation of Surgical Safety Checklist includes anesthesiologists involvement

SAQ #4

WHAT INFORMATION IS USED TO DECIDE ON THE RANGE OF THE TEAM’S SERVICES? GREEN, LOW
Summary of Related Standard(s):
1.1 The team collects information about its clients and the community.
1.3 The team’s scope of services is aligned with the organization’s strategic direction.
1.5 The team regularly reviews its services and makes changes as needed.
Process Currently in Place - Evidence of Current Status
• Historical utilization reports from Canadian Institute for Health Information
• WTS (Wait Time Strategy)
• Service specific information-clients are from specific internal programmes ie: Schulich, oncology, opthalmology, gyne, plastics, trauma, medical imaging
• CCAC, PT/OT, nursing arrangements in PAC/SSSU-for clients who need additional support in the community
• PAC redesign project
• New SSSU, and ongoing expansion of its’ services from 6-8 beds
Improvement Strategy / Action Plan
1. Develop PAC policy (Carol, Ramona, Pam)
2. Develop nurse/telephone process (Pam, Ramona)
3. Update SSSU policy (Carol, Ramona)
4. Expansion of SSSU to 11 beds (Carol, SSSU staff)

SAQ #3

DOES THE TEAM ASSESS THE CLIENT’S MEDICATIONS AT ADMISSION? GREEN FLAG, HIGH PRIORITY
Summary of Related Standard(s): 7.10 7.11 REQUIRED ORGANIZATIONAL PRACTICE: The team reconciles the client’s medications upon admission to the organization, with the involvement of the client.
Process Currently in Place - Evidence of Current Status
• Patients are instructed to bring their medications to PAC and SDS with them in their original containers
• Patients have written instructions in ‘Day of Surgery’ booklet on which medications to take on the morning of surgery
• Medications are listed on the anesthetic questionnaire
• Transcribed by RN onto Patient Medication Form and checked for accuracy with patients.
Improvement Strategy / Action Plan
November 2009 - February 2010
1. Same Day Surgery PAC : are they able to reconcile pt's medication on inpatient medication record document? Does one need to be developed for outpatients?'

SAQ #2

BEFORE PROVIDING SERVICES, IS THE CLIENT’S INFORMED CONSENT OBTAINED? GREEN FLAG, HIGH PRIORITY
Summary of Related Standard(s) 8.1, 8.2, 8.3, 8.4, 8.6
Process Currently in Place - Evidence of Current Status
· Surgeon obtains informed consent in the office. The original consent is placed in the chart at end of PAC appointment
· Verified on Day of Surgery and also during the PAC appointment
· APPLE PIE and TIME OUT done by OR staff includes anesthesia
Improvement Strategy / Action Plan
November 2009 - February 2010
1. Surgical checklist
2. Block checklist being implemented in Regional block area
Communication / Staff Training / Education Plan
· Delia participated in Grand Rounds outlining Block area responsibility with regards to safety checklist
· PILOT done in Nov/Dec in Block area.

SAQ #1

PeriAnesthesia Accreditation 2010
Self-Assessment Questions (in order of priorities)
1. DOES THE TEAM HAVE SPECIFIC WAYS TO MONITOR ACTIVITIES THAT ARE HIGH-RISK, E.G. CRITICAL TESTS, OR MEDICATION ADMINISTRATION? RED FLAG, HIGH PRIORITY
SUMMARY OF RELATED STANDARD(S): 15.4 REQUIRED ORGANIZATIONAL PRACTICE: The team uses verification processes and other checking systems for high-risk activities.
PROCESS CURRENTLY IN PLACE:
• Independent Double Check (IDC) for high risk meds insulin and heparin, PCA's and Epidurals
• E-safety reports on near misses and adverse events
• Equipment alarms. Equipment is sent to biomed if it is not working. PCA and Epidural pumps are regularly checked by biomed.-new pain pumps to be implemented possibly in March 2009 -will require in servicing
· SMART pumps being rolled out December 2009
· Block Safety Checklist
· McKessin cabinets for narcotics on MGround and M2 PACU
IMPROVEMENT STRATEGY / ACTION PLAN
July 2009- October 2009
-IDC implemented over the summer
-E-safety reports are encouraged to be completed.
-ongoing equipment repairs are done through Biomed
November 2009 - February 2010
1. McKessin cabinet rollout Nov 17th. Super users: Ramona, Carly, Deborah K
2. Symbiq SMART pumps rolled out in December. Super users: Ramona, Carly, Carrie, Debbie Mulgrave, Sirkka
3. Block safety checklist to be implemented in Jan 2010. Ramona, Carol, Delia
4. Novo glucose meters will be rolled out in January
March 2010 - onward
1. New pain pump rollout? Will need volunteer super users.
Plan for spreading improvement to related services / areas?
With units moving on Mground, SSSU RN's will need to be in serviced on McKessin cabinets

Inhaled Anesthetics (Health & Wellbeing: Anesthesiology)

Happy New Year!
It's been a while and I thought I would upate our blog. I hope you find this interesting!

Inhaled Anesthetics (Health & Wellbeing: Anesthesiology)