Surgical Safety Checklist (SSCL) - CMH



Board ReportFrom CMH President & CEOApril 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 as of March 31, 2018.WIG: Occupy Wing AOfficial: May 31 Likely: Aug-SeptSuper-user training tentatively scheduled early MayDraft move sequence completed – seeking feedbackBadge issuance – Completed 1,240; 831 remaining WIG: Program GrowthApproved growth plans in development for Woman & Child, Focused Mental Health and Specialized SurgeryDraft growth plan for GI & Liver Health in consultation phaseWIG: Patient & Staff EngagementWould you recommend? 50.2% (goal: 60% by March 31, 2019)Exploring corporate and departmental initiatives to improve both“Clinician Heal Thyself” workshop underway in EmergencyDefining our RoleCommunity Medicine clinic started (see Quality section)Improve QualityHuddle refresh with clinical units continuesDrive Value and Affordabilitye-referral project for DI (see below)Strengthen PeopleDept. action plans Target 100% 39% completed29% in progress32% not yet startedFinances 2017-18 (March)Reported in Resources reportSpecial DatesMay – CMH Food Drive140335000Goal: To safely and successfully transition from Wing B to the new Wing A and Wing C. Wing A handover updateProjectCo has moved the hand over date to May 31. While this date is closer to our estimates, we continue to seek counsel from Infrastructure Ontario and our capital redevelopment staff as to when we might get access to the new Wing A. Other updatesNew ID badges have been issued and old card readers are being swapped out for new ones. The new badges will provide staff and physicians with access to new security systems and these card readers. NEW: Patient experienceNEW: Staff engagementNew WIGs for planned 2018-19Two "wildly important goals" (i.e., WIGs) are being planned for 2018-19. For those who are new to the organization, a WIG is a priority that will ultimately make us fail if it is not achieved. It is intended to provide organizational focus and alignment - that is, help focus effort and work for staff and leaders in the organization.“Patient Experience” – Given the government's recent announcement that it intends to link quality indicators to funding (e.g., receiving enough information at discharge), enhancing the patient experience will be a prime focus over the coming year. “Staff engagement” – Building on the work of these past few years, staff engagement will continue to be a priority for the hospital. At this time, departmental WIGs are under development. More will be shared as metrics for each WIG are finalized.Improve QualityEVS boosts its safety arsenal with NocosprayThe Environmental Services Department (EVS) acquired a new,?easy-to-use disinfection system that will help reduce healthcare related infections in our hospital. Nocospray converts a liquid, hydrogen peroxide based disinfectant into a dry, disinfectant gas. This allows the air and hard surfaces in a room to be treated at the same time. It is non-toxic, non-corrosive, non-oxidizing and does not create germ resistance. It is also approved as a sporicidal option for hard surface disinfection. Nocospray does not replace the important first step of manually cleaning and is always used after our cleaning process. How it works:After a room is cleaned, the machine is placed in the room on a cart (see above)The system kills pathogens, not equipment! Cleaned equipment can be pushed into the room for added safety.Nocolyse (the disinfection agent) is measured according to room size and added to the machine.The machine is turned on and room is closed offAfter the dosing is complete the room will sit for 45 minutes before anyone is allowed to enter.New Community-based Medicine Clinic at CMHAs part of our vision to offer quality and integrated patient care, a specialized Community-based Medicine Clinic was opened the week of April 9 to provide rapid access to for patients to receive an Internal Medicine consultation. Patients are referred to the program from the Emergency Department of after discharge from one of our inpatient units. The purpose of the clinic it to provide timely assessments to find changes in medical conditions, review results of tests ordered in hospital and to facilitate additional testing if there is a need. Drive Value and AffordabilityDI eReferral goes live in Waterloo WellingtonSystem Coordinated Access Program, which is hosted by the eHealth Centre of Excellence, shared some exciting news for patients in the Waterloo Wellington region. The week of March 26, all seven hospitals in the Waterloo Wellington region took a significant step to improve the patient experience by introducing an electronic referral (eReferral) solution as a way to process Diagnostic Imaging (DI) referrals. This use of technology will not only streamline the referral process for family physicians, specialists and DI hospital staff, it will also decrease administrative delays for patients in need of X-rays, MRIs, CTs or other diagnostic imaging tests.Prior to eReferral, patients could wait weeks to be notified of their appointment. This new system provides patients with an option of email notification throughout the booking process and includes the ability to confirm their appointments from email. Patients may also choose their referral by location. In addition, real-time communication ensures patients have all the relevant information at their fingertips, including how to prepare for their appointment. Our hospital is a champion and leader for this technology, having implemented an eReferral solution in November 2015.Our experience was invaluable into the region-wide implementation and launch of the system at the end of March. Honourable Kathryn McGarry visits CMHMinister of Transportation and local MPP Kathryn McGarry visited CMH on March 23 to announce a funding increase of $1.99M to the hospital’s budget. This was welcomed news – in some years, it is many months before the hospital before the hospital receives its funding notice. More will be shared as we receive further direction from our ministry on this funding. Strengthen our PeopleOntario Service AwardsOn Wednesday, April 4, some of our very own volunteers were honoured by the Province at the Ontario Volunteer Service Awards. Recipients included:Barb LeBrun, 35 Years Ernie Crump, 10 Years Betty Hetherington, 10 YearsSheena Quigg, 5 YearsRobert Miller, 5 YearsPaige Haimes, YouthKayleen Ryan, YouthJasmine Soomal, YouthWe applaud all recipients and thank you for your continued years of service and caring at CMH!Welcome April McCulloch - ManagerApril McCulloch joined CMH as Manager, Intensive Care Unit, Medical Day Care & Respiratory Therapy on April 16, 2018. April is an experienced leader, successfully advancing care for patients and managing teams within regional programs for close to 10 years. She comes to us from the William Osler Health System where she manages their Cardiac Procedures Unit, Cardiac Catheterization Lab and Arrhythmia Program. April’s other clinical experiences include cardiac catheterization lab, cardiac catheterization recovery, outpatient clinics, adult and pediatric intensive care. April holds a diploma in Nursing from Mohawk College and a Bachelor of Science in Nursing from St. Francis Xavier University. She has been a leader in program design, development, project management, and has many years of experience coaching and engaging teams to improve quality, performance and the patient experience.Welcome Jennifer VisocchiMs. Jennifer Visocchi is joining CMH in the role of Director of Pharmacy. She starts her new role May 14, 2018.Jennifer is a licensed Pharmacist with the Ontario College of Pharmacists and has over 21 years of hospital pharmacy clinical and management experience. Jennifer comes to us from Brant Community Healthcare System (BCHS), having held the positions of Group Leader, Pharmacy, Clinical Pharmacist and Pharmacy Clinical Coordinator. Jennifer was also a Clinical Pharmacist and Senior Pharmacist for Hamilton Health Sciences for many years, and the Site Manager for the Juravinski Hospital.Jennifer’s accomplishments include spearheading major change projects including the integration of BCHS with West Haldimand General Hospital, onboarding of Northwest Telepharmacy for overnight services, implementation of an electronic MAR in Critical Care, and leading the med rec process as part of the hospital QIP.She sits on the Community Opioid Strategy Working Group in Brantford and Brant County, is the lead for the BCHS Medication Reconciliation Steering Committee, and is a preceptor for the Pharmacy Student, Intern and Co-op programs with the Ontario College of Pharmacists, University of Waterloo School of Pharmacy, and the University of Toronto. ................
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