Wednesday, July 28, 2010
Friday, July 9, 2010
Thursday, June 3, 2010
SAQ #49
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)
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
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
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
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
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
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
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
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
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
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
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
Monday, April 5, 2010
Friday, March 26, 2010
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
Monday, March 15, 2010
SAQ #30
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