Championing accreditation readiness

In November 2013, achieved its first formal as a three-site hospital. Getting to this point as a recently merged organization offered a unique learning opportunity, and a chance to highlight the new organization’s commitment to quality and excellence through extraordinary teamwork across the hospital’s three sites.

“The staff at all sites are committed and engaged. Enthusiasm is a hallmark of all the care teams that were encountered during the Accreditation Survey,” said Accreditation Canada’s surveyors during the formal debrief at Trillium Health Partners. “At the care team level, managers have empowered their employees, which have contributed to the engagement of the staff.”

As Trillium Health Partners staff reflected on what it takes to embed leading practices into

organizational culture, an important question came up. “I thought – if incorporating best practices into our daily activities is really important, then why don’t we do better at focusing on them every day?” says Jarmila Grof, Clinical Educator, Trillium Health Partners. “It’s about accountability; it is everyone’s responsibility to practice according to the latest standards and evidence. You wouldn’t want to dine in a restaurant that did not pass its health inspection. The same translates to us:  we want to work in an environment where quality of care and patient and staff safety is a top priority, and where we have the highest expectations of one another to achieve that,” adds Grof

This question and the commitment from the front lines led Trillium Health Partners’ leadership to develop a comprehensive Accreditation Sustainability Plan, helping to champion best practices within the hospital. The plan is a unique, leader-led championship model that looks at innovative ways to integrate patient safety and quality standards into daily operations. Since its implementation in November 2014, the plan has already shown significant impact on patient care and experience.

“The sustainability work has helped us translate the expectations set out by Accreditation Canada to simple, tangible examples of how we embed its recommendations into our day-to-day practice,” says Heather Ead, Clinical Educator, Trillium Health Partners.

The plan includes an interactive audit conducted across the organization every three- four months by “mock tracers” reviewing key quality practices across different program areas, as well as a thorough sustainability assessment similar to performing a mock accreditation, but on a smaller-scale. It is designed to determine which key quality practices have been successfully adopted into the hospital’s daily routines, and to identify gaps. In November of 2016, a simulated survey will be conducted by the hospital’s in-house surveyors and quality team members. This will provide a baseline assessment to inform the planning for the hospital’s next Accreditation Canada Survey in November 2017.

Since launching the Accreditation Sustainability Plan, the team has conducted 77 mock tracers across various program areas and has engaged more than 74 patients, all to enforce and assess day-to-day practices.

“Our mock tracers encourage open communication with our surveyors about quality and patient safety practices. Through these experiences, our front line team members have made excellent suggestions on where and how improvements can be made,” says Tara McCarville, Vice President, Quality, Enterprise Risk & Business Intelligence. “It’s also been encouraging to hear from our patients. Their first-hand input has helped us refine our quality and patient safety program, and how to reinforce what we are doing right, and highlight what we can do better to improve their care,” McCarville adds.

In a mock tracer event, one patient noted, “I feel safe here. It cannot be understated how important these relationships with the teams are. They make the experience positive; they provide hope and make it feel like home. I actually look forward to coming for my treatments.”

“Kudos to Trillium Health Partners for supporting a program that has embedded accreditation into its fabric as an ongoing program of quality improvement,” says Dr. Norman Hill, Vice President, Medical Administration, and in-house surveyor at Trillium Health Partners. “Accreditation shouldn’t be looked on as a necessary project that comes around every four years, but as a mechanism by which we can continuously improve the quality of care we deliver to our community every day.”

Trillium Health Partners is the largest community hospital serving residents in Mississauga and West Toronto. The hospital’s Accreditation Sustainability Plan is a proactive approach allowing a continuous, sustained focus on best practices to deliver quality, safe care, and has the hospital well positioned to undergo its second formal Accreditation in 2017.