Surgical Safety Checklist (SSCL) - CMH



Board ReportFrom CMH President & CEONovember 2018 This report provides a brief update on some key activities within CMH as an FYI. While it is organized by our wildly important goals (WIGs) and our 2017-19 strategic themes, it may include other appropriate projects. As always, I’m happy to answer questions and discuss issues within this report or other matters. Here is a quick “snapshot” of some of the key work underway as of October 2018. WIG: Patient Experience (PX)By March 31, 2019 we will improve the performance of patients answering to the questions “Did you receive enough information from staff…” and “Would you recommend...”Work proceeding on medication reconciliationCoHealth app launchedCorporate strategy in developmentWIG: Staff EngagementBy December 31, 2019 we will improve the performance of staff answering the question”…How would you rate CMH as a place to work?”Baseline: 36% Target: 53% (very good to excellent)October – 37% Wing A HandoverOfficial: December 3Training Material: Needs completed resolution on nurse call, Olympus, RTLS and other systems Bonding Agency now involved and paying off trades so that they can come back to workDefine our RoleApproved growth plans for Woman & Child, Focused Mental Health, Specialized Surgery,?Specialized Medicine (GI & Liver Health) to be finalized for Board approval by March 2019. These are in development and will be shared with the MAC when ready in a draft format.Improve QualityED treat and release pathway/fast track Recruitment of strong operational leaders with QI backgroundsHuddle refresh on track with clinical units. Quality & Ops commenced with new formatDrive Value and AffordabilityImplement new models of care in Medicine A complete, mental health outreach, redesign paths for congestive heart failure and palliative care servicese-referral project for DI completeStrengthen PeopleAnnual reviews of leaders completedFinancialsTarget surplus: $ 1.0MForecast surplus: $ 2.2MPatient experience Improve QualityPharmacy innovates to reduce missing signaturesCMH is required by law to keep records of narcotic waste and each record needs to be co-signed. In the past, a pharmacy technician spent a lot of time compiling lists of outstanding co-signatures and sending them to managers to follow-up with their staff to complete the required documentation. Pharmacy staff had an idea to reduce and even eliminate the missing signatures. A pilot project was designed with Surgery, where they often prescribe narcotic medicine to help ease their patient’s pain after an operation The idea was to proactively print the report one-hour before shift change with the needed names and co-signatures. This simple solution allowed the charge nurse to follow up with staff to complete the documentation prior to the end of their shift. Although they are currently working through a few process issues with printing the report, Pharmacy has seen a significant decrease in unreconciled signatures. Once these printing issues are resolved, the plan is to initiate this new process hospital wide.Congratulations Pathology!Our Pathology team does it again! Cancer Care Ontario acknowledged our Pathology team for meeting the provincial annual improvement target for "Pathology post-surgical turnaround time for all disease sites."?Engaging staff with their safetyOver the coming weeks, managers and directors will engage staff to identify an area where they can safely leave and consume food and drink (and apply cosmetics)An algorithm for assessing areas within their workplace was shared with staff. In short, four criteria need to be satisfied:Do patients enter the area?Is medication prepared or stored in the area?Are there any chemicals stored in the area?Are specimens stored or placed in the area?If they answered “NO" to all of these criteria, food and drink may be consumed in the area. If they answered “yes” to any, it will be up to the team to determine whether practices can change so to make the area safe. For example, if an area qualifies on all counts except for the storage of medication, can the team change their practice to put medicines elsewhere so that the area can be qualified as safe.The Ministry of Labour has made it known to health care organizations that staff leaving food and drink in areas that are not safe can result in fines. Emily MacDougall to support AccreditationBetween November 4-7, 2019, Accreditation Canada surveyors will compare our quality systems and processes against national standards. New with this survey are substantially enhanced requirements for co-designing care with patients and expectations around medication reconciliation at discharge and all transfer points. A successful Accreditation Canada survey will require focused attention by all. To prepare the organization and coordinate our efforts, Emily MacDougall CEF has been enlisted to provide education and focus on Required Organization Practices (ROP). Emily starts later this month (November 2018) support this project two days per week. She will adjust and increase her time on this project as we near the on-site visit dates.The ‘dope’ on recreational marihuanaNow that recreational marihuana is legal, here are a few things you should know about what has changed. Marihuana may be consumed in the home, yet?at schools or hospitals, in motorized vehicles, enclosed public spaces?and in other areas, it remains illegal. CMH is finalizing a “Fitness for Duty” policy that covers everyone – staff, physicians, students and volunteers - on any substance that can make our work environment unsafe. In short, it mirrors current Occupational Health and Safety regulation that charges an employer to take every reasonable precaution to ensure a safe work environment. This means there is zero tolerance to taking risks with staff and patient safety. Ontario hospitals are waiting to hear from the OHA regarding a limit that establishes impairment. To help you make an informed decision, it is recommended that you abstain from recreational cannabis 12-24 hours before you are scheduled for work because current tests can detect usage within this timeframe.?Drive Value and AffordabilityWing A: Handover delayed to December 3The contractor announced on August 24 that the handover of the new patient care wing will be delayed to December 3. This was their eighth delay this year. The original schedule noted November 2016 as the handover month. As of November 20, we have not received a viable plan outlining how the contractor will handle the remaining work and address the building’s deficiencies. There has also not been any substantial work done to the new Wing. We firmly believe the December 3 handover will not be met. Code Grey – Wing B heating failureOn November 14, a code grey (external air exclusion or loss of essential service) was announced and solutions were put in place because of the lack of heat in Wing B. This was due to a broken heating coil that was discovered in August. Although a new one was ordered right away, the coil is part of a custo’ heating system that requires it to be manufactured by a company in the States. Our new Facilities manager, Jason Smith and his team fortified the the heating with two rented diesel heaters, multiple space heaters and by cobbling together parts in the existing system to help modulate the heat. These strategies helped maintain a high standard of care and safety for our patients and staff. The hospital learned on November 17 that the needed part was finally manufactured, tested and on route to Canada.?Strengthen our PeopleDr. Kathryn Sawa – plastic surgeonDr. Kathryn Sawa recently joined as a Plastic Surgeon. She completed her fellowship in Oncologic and Microvascular Reconstruction at Sunnybrook Health Sciences Centre in Toronto. Prior to her fellowship, Dr. Sawa completed her residency in Plastic and Reconstructive Surgery at Western University. Dr. Sawa has been involved in a number of research presentations and publications since 2011. In 2016, Dr. Sawa was Chief Resident, Plastic and Reconstructive Surgery at Western University. Please welcome Dr. Sawa to CMH.Jason Smith – manager, Physical Plant and PropertyJason Smith joined us on October 29, 2018 as our manager of Physical Plant and Property. He comes to us with over 17 years’ experience in the area of maintenance operations and facilities management. Jason is currently the Director of Facilities Management at St Michael’s College School (Toronto). As a key member of the six person Executive Council leadership team, Jason was accountable for the portfolio of Maintenance, Construction, Housekeeping, Security, IT, Theater, Farm, Arena and Rentals for the 1,000+ student campus. Prior, Jason also worked for the Ontario Lottery & Gaming (OLG) Corporation, where he was the Director of Facility Management, accountable for 31 province wide OLG locations, totaling over 7 million square feet, and staff reports in excess of 1,000 unionized and non-unionized employees. Jason will be responsible for all of CMH’s services related to Maintenance, Biomedical Engineering, Security, Parking, Snow Removal and Grounds, as well as support some of other key initiatives such as the Capital Redevelopment Project.Thank you, Sonya!For the past six months, Sonya Kochanski has more than ably led the Rehab Unit as their interim manager. On November 12, she will return to her regular assignments with the Allied Health team and the lead for Ergonomics within the Hospital. The search for a new manager is underway. Until then, Julese Chesney will add the Rehab Unit to her role as interim manager of Inpatient Surgery. Thank you Sonya for your leadership and the stability you provided your team. ................
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