Surgical Safety Checklist (SSCL) - CMH



CMH Board of Directors ReportFrom CMH President & CEOSeptember 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 September 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 reconciliation, launch of CoHealth appCorporate strategy still 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)August – 42%Wing A HandoverOfficial: December 3.Training Material: Needs completed resolution on nurse call, Olympus, RTLS and other systems Define 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 2019Improve 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: $ 2.2MJune YTD Actuals: $ 588kSick :$26K over budget YTDOvertime : $ 225K over budget YTDSpecial DatesOctober 10 – Thank you eventOctober 31 – Pumpkin Carving ContestPatient experienceCoHealth app launch a successOn September 18, we celebrated the launch of the innovative CoHealth app in the Women and Children's program. CMH is the first hospital within the region to use this smartphone based application, which provides obstetrical patients free access to aftercare information and links to local resources. It also includes a five-question survey asking about the patient's experience at the hospital, giving us nearly real-time feedback when normally there's a lag.Work is underway to expand it to other programs, including hip and knee surgery and rehabilitation. Work is underway to expand it to other hospitals, following the app developer receiving $250,000 from the Waterloo Wellington Local Health Integration Network this past spring to create a local version.Improving the surgery patient experienceAs a means to improve the surgery patient experience, two Pre-Op clinic clerical clerks were added to the Surgery Team recently. Asifa Achchha and Tiffany Robert are the trailblazers for this new initiative that will start our journey to bring services to patients, rather than shuttling them from spot to spot. Not only will they begin to register patients for their Pre-Op appointments - currently performed by their colleagues in Central Registration, they will also do the information collection processes that support nurses and anaesthetists in the clinic. Both Asifa and Tiffany started the first week of August, with the goal of having them both fully integrated into their roles by mid-September. The Pre-Op Clinic is in the Wing B Surgical Day Care waiting room area and will run Monday to Friday, 0700 – 1500h. Staff engagementAshenhurst Scholarship Grant programThe Ashenhurst Scholarship Grant was created by Barb and Peter Ashenhurst, through the CMH Foundation. The vision is to support the studies of a current CMH Nurse, practicing caregiver, or medical student to proceed with a project that provides education to CMH staff addressing the needs of patients living with Chronic Obstructive Pulmonary Disease (COPD). One candidate will be awarded $3,000 to learn and proceed with an education plan. The incumbent will also commit to providing a summary of activities within 12 months of receiving the award. Define our roleNeurology Clinic now openWe are pleased to welcome Dr. Amir Ilyas, Neurologist to CMH! Dr. Ilyas is offering a new and much needed Neurology service for our inpatients and the community. His special interests include epilepsy and headaches. The Neurology Clinic is located in the same area as our Sleep Clinic on Wing C, Level 2, room 2.300, 303 and 305.Endoscopy is growing!The Endoscopy program at CMH has grown to better support our patients with timely access to care. In doing so, patients presenting with symptoms needing this important procedure now have quicker access and will need to wait less for a diagnosis. In cases of cancer, this is important as it enables the patient to access care earlier. To grow the program, a second endoscopy room was made available at the end of July, which added four more days to perform endoscopy procedures. This could not have worked without the steadfast collaboration of our Endoscopy team with many internal stakeholders including the Lab, physicians, and Information Technology.New RAAC to be placed in the communityOn Aug. 8, a formal announcement was made regarding the location of Cambridge’s Rapid Access Addictions Clinic (RAAC). You may recall Cambridge Memorial Hospital was the original site for the RAAC. Unfortunately, on-going construction and space constraints at the hospital have made our location unavailable. The responsibility to provide this much-needed service prompted a trial-run at the nurse practitioner led clinic on Water Street in Cambridge. Still, we are a key partner for this service, through ED supports and referrals. We also see value in admission diversions and follow-up.The RAAC is a specialty medical clinic designed for people who are experiencing health issues related to their drug and/or alcohol use. The clinic welcomes people of all ages who are currently using substances. The RAAC is a short-term service and patients are connected back to their primary care provider upon completion of their involvement. Improve QualityMental Health First Aid TrainingIn September, a number of our staff participated in a two-day OHA delivered course called “Mental Health First Aid Training.” The goals of the course are to create a psychologically safe workplace and support staff who may be suffering from mental health issues. Staff learned tools they can use in the workplace that include:Recognizing and understanding the symptoms of mental health problemsProviding assistance to prevent the mental health problems from developing into a more serious statePromoting the recovery of good mental health by accommodating employees in distress or recovering from a crisis As an organization dedicated to continuous improvement, we continue to seek ways to enhance our work-life environment and the ways we support our staff. Accreditation updateWe are almost three years removed from our last Accreditation on-site visit. In November 2015, we were assessed against 2223 criteria in eight quality dimensions, meeting all but 14. Of those, 60 out 60 minor and 297of 300 major “required organizational practices” were also met. Accreditation 2019 will place new challenges on CMH. The inclusion of “Patients as Partners” will be a large change in practice for all hospitals. In short, patient engagement will no longer be a rubber stamping exercise of already approved policies and procedures. For example, hospitals will need to co-design services with real input from clients, patients and families, including the co-creation of service specific goals. As a means to ensure patients et al. are partners and shared leaders with hospitals, the surveyor team for the on-site visit will include a patient surveyor. More will be shared with the Board as we ramp up for Accreditation 2019. In short the timeline will be as follows:Summer 2018: Teams assembled, gap analysis beginsFall 2018: Safety and Culture Survey administeredFall 2018: Action plan development for Safety and Culture SurveyWinter 2019 – Fall 2019: Policy updates, closing identified gaps, implementing action plansLate summer 2019 – November 2019: Final prep for onsite visitERAS relaunched in JulyOn July 24, CMH relaunched the Enhanced Recovery after Surgery (ERAS) program. This pilot project was developed last fall with the goal to standardize aspects of a patient’s surgical care journey. It included the development of new patient teaching materials, order sets, and patient monitoring systems relating to minimally invasive surgery (MIS) of the bowel. MIS leads to faster healing and a reduction in the overall length of stay on the surgical unit. The addition of ERAS allows patients to return to their normal life more quickly than past approaches to bowel surgery. A huge thank you to all staff and physicians involved in this project from Inpatient Surgery, General Surgery, Anaesthesia, our Acute Pain Service, and the OR!Kudos to our physicians and PharmacyOne of CMH’s two community based quality improvement plans (aka c-QIP) is to improve medication reconciliation at discharge for patients with congestive heart failure (CHF). The goal was to reduce readmission for patients with CHF, after a medication reconciliation review demonstrated gaps and opportunities in our processes. At a recent community meeting, a community –based pharmacist from Preston Medical noted a significant improvement with our new ‘medication reconciliation at discharge’ forms. The pharmacist could not yet quantify the decrease in errors, but estimated a 30% improvement due to the clarity with home medications. Great feedback and a testament to the tireless energy our physicians in partnership with our Pharmacy staff have put into this initiative. Well done! Pharmacy builds on its safety cultureOur Pharmacy Department received their report from the Ontario College of Pharmacists (OCP) who visited them earlier this month. In total, 101 standards were measured, from narcotic orders to administration and documentation, on patient care floors and within the Pharmacy Department. It met or partially met all of them, receiving an accreditation rating of “Pass with Action Plan.” This means partially met standards will require fully developed action plans with timelines, within 30 days. Pharmacy will also engage nursing staff on the implementation of a fentanyl patch-4-patch program to meet narcotic standards. One critical safety element from their 2016 visit remains outstanding. The OCP noted the building of a new hazardous and non-hazardous compounding facility has been funded and the process to meeting this requirement is initiated. As written in the report: “[CMH] demonstrates a commitment to a safe medication system. Since the last visit, the site has made changes based on the last OCP recommendations to continue to build on this culture.” The Pharmacy team wishes to thank all staff who interacted with the accreditors during their visit. Breastfeeding Buddies Breastfeeding Buddies is a new volunteer program supporting new moms establish a positive breastfeeding experience. The volunteers are breastfeeding mothers with at least six months breastfeeding experience and have completed a certified training course. They visit breastfeeding moms on the postpartum unit and offer peer support and encouragement to help build confidence. They also connect patients in need with community breastfeeding buddies and resources.CMH’s Endoscopy Unit receives quality awardThis summer, CMH’s Endoscopy Program received the CAG Quality Endoscopy Recognition Award by the Canadian Association of Gastroenterology (CAG). CAG offers endoscopy units to take part in a global rating system that assesses the unit’s patient centered quality of endoscopy care. The award reflects the commitment of to providing exceptional care and its continued commitment to quality improvement in digestive endoscopy. It highlights the collaborative working relationship between our endoscopists, surgery nurses and support staff. CMH’s Endoscopy Program is led by Dr. Augustin Nguyen, chief of Medicine, Alean Jackman, manager of Perioperative Services and Jane Linton, charge nurse for endoscopy. 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. We believe this is closer to our estimate of having this building in late fall, early winter and it is technically achievable. At this time, we have not received a viable plan outlining how they will handle the remaining work and address the deficiencies, so we remain wary of this new deadline. This is the eighth delay this year. The original schedule noted November 2016 as the handover month. World Architecture Festival and AwardsWorld Architecture Festival (WAF) is an annual celebration of global architecture that sees practices around the world compete for the title of World Building of the Year. This year, 536 architectural words are shortlisted, and divided into categories depending on their purpose and whether they are completed or a future project. WAF will be held in Amsterdam this year from November 28-30, where the winners from each category will be announced. Winners of those categories will then complete to be crowned World Building of the Year. This year, we are thrilled to announce that Cambridge Memorial Hospital has been shortlisted in the category Health - Future Projects!Strengthen our PeopleEmily MacDougall, RN – Best Practice ExpertWe are very proud to announce that Clinical Educator and Facilitator Emily MacDougall was chosen as an expert panel member for the Vascular Access Best Practice Guideline (BPG)! Over the coming months, Emily will share her expertise with other experts during a series of in-person and virtual meetings. She will also participate in the creation of recommendation statements and performance indicators that will shape nursing practices provincially, nationally and internationally! The Registered Nurses’ Association of Ontario is a leader in the development of relevant, evidence-based BPGs that guide nursing practices. An important part of the guideline development process involves consultation with expert health care providers - like Emily - from a wide range of practice settings. Congratulations Emily! ................
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