Portage · Portage (referred to in this report as “the organization”) is participating in...

Accreditation Report

Portage

On-site survey dates: June 16, 2013 - June 21, 2013

Accredited by ISQua

Montréal, QC

Report issued: August 13, 2013

Confidentiality

This report is confidential and is provided by Accreditation Canada to the organization only. Accreditation Canada does not release the report to any other parties.

In the interests of transparency and accountability, Accreditation Canada encourages the organization to disseminate its Accreditation Report to staff, board members, clients, the community, and other stakeholders.

Any alteration of this Accreditation Report compromises the integrity of the accreditation process and is strictly prohibited.

About the Accreditation Report

Portage (referred to in this report as “the organization”) is participating in Accreditation Canada's Qmentum accreditation program. As part of this ongoing process of quality improvement, an on-site survey was conducted in June 2013. Information from the on-site survey as well as other data obtained from the organization were used to produce this Accreditation Report.

Accreditation results are based on information provided by the organization. Accreditation Canada relies on the accuracy of this information to plan and conduct the on-site survey and produce the Accreditation Report.

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© Accreditation Canada, 2013

A Message from Accreditation Canada's President and CEO

On behalf of Accreditation Canada's board and staff, I extend my sincerest congratulations to your board, your leadership team, and everyone at your organization on your participation in the Qmentum accreditation program. Qmentum is designed to integrate with your quality improvement program. By using Qmentum to support and enable your quality improvement activities, its full value is realized.

This Accreditation Report includes your accreditation decision, the final results from your recent on-site survey, and the instrument data that your organization has submitted. Please use the information in this report and in your online Quality Performance Roadmap to guide your quality improvement activities.

Your Accreditation Specialist is available if you have questions or need guidance.

Thank you for your leadership and for demonstrating your ongoing commitment to quality by integrating accreditation into your improvement program. We welcome your feedback about how we can continue to strengthen the program to ensure it remains relevant to you and your services.

We look forward to our continued partnership.

Sincerely,

Wendy NicklinPresident and Chief Executive Officer

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A Message from Accreditation Canada's President and CEO

Table of Contents

1.0 Executive Summary 1

1.1 Accreditation Decision 1

1.2 About the On-site Survey 2

1.3 Overview by Quality Dimensions 3

1.4 Overview by Standards 4

1.5 Overview by Required Organizational Practices 5

1.6 Summary of Surveyor Team Observations 7

2.0 Detailed Required Organizational Practices Results 9

3.0 Detailed On-site Survey Results 10

3.1 Priority Process Results for System-wide Standards 11

3.1.1 Priority Process: Planning and Service Design 11

3.1.2 Priority Process: Governance 12

3.1.3 Priority Process: Resource Management 13

3.1.4 Priority Process: Human Capital 14

3.1.5 Priority Process: Integrated Quality Management 15

3.1.6 Priority Process: Principle-based Care and Decision Making 16

3.1.7 Priority Process: Communication 17

3.1.8 Priority Process: Physical Environment 18

3.1.9 Priority Process: Emergency Preparedness 19

3.1.10 Priority Process: Patient Flow 20

3.1.11 Priority Process: Medical Devices and Equipment 21

3.2 Service Excellence Standards Results 22

3.2.1 Standards Set: Customized Infection Prevention and Control 22

3.2.2 Standards Set: Customized Managing Medications 24

3.2.3 Standards Set: Substance Abuse and Problem Gambling Services 25

4.0 Instrument Results 30

4.1 Governance Functioning Tool 30

4.2 Patient Safety Culture Tool 34

4.3 Worklife Pulse Tool 36

Appendix A Qmentum 38

Appendix B Priority Processes 39

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iTable of ContentsAccreditation Report

Portage (referred to in this report as “the organization”) is participating in Accreditation Canada's Qmentum accreditation program. Accreditation Canada is an independent, not-for-profit organization that sets standards for quality and safety in health care and accredits health organizations in Canada and around the world.

As part of the Qmentum accreditation program, the organization has undergone a rigorous evaluation process. Following a comprehensive self-assessment, external peer surveyors conducted an on-site survey during which they assessed this organization's leadership, governance, clinical programs and services against Accreditation Canada requirements for quality and safety. These requirements include national standards of excellence; required safety practices to reduce potential harm; and questionnaires to assess the work environment, patient safety culture, governance functioning and client experience. Results from all of these components are included in this report and were considered in the accreditation decision.

This report shows the results to date and is provided to guide the organization as it continues to incorporate the principles of accreditation and quality improvement into its programs, policies, and practices.

The organization is commended on its commitment to using accreditation to improve the quality and safety of the services it offers to its clients and its community.

1.1 Accreditation Decision

Portage's accreditation decision is:

Accredited (Report)

The organization has succeeded in meeting the fundamental requirements of the accreditation program.

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Executive SummarySection 1

Executive Summary 1Accreditation Report

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1.2 About the On-site Survey

• On-site survey dates: June 16, 2013 to June 21, 2013

• Locations

The following locations were assessed during the on-site survey. All sites and services offered by the organization are deemed accredited.

1 Centre d'accueil le Programme de Portage - Portage Lac Écho

2 Centre d'accueil le Programme de Portage - Portage Lionel-Groulx, programme TSTM

3 Centre d'accueil le Programme de Portage - Portage Québec

4 Centre d'accueil le Programme de Portage - Portage Square Richmond

5 Centre d'accueil le Programme de Portage - Portage St-Malachie

6 Centre d'accueil le Programme de Portage - Portage West-Island

7 Portage Program for Drug Dependencies - Portage Atlantic

8 Portage Program for Drug Dependencies - Portage British Columbia

9 Portage Program for Drug Dependencies - Portage Ontario

• Standards

The following sets of standards were used to assess the organization's programs and services during the on-site survey.

System-Wide Standards

Leadership1

Governance2

Service Excellence Standards

Substance Abuse and Problem Gambling Services3

Customized Infection Prevention and Control4

Customized Managing Medications5

• Instruments

The organization administer:

Governance Functioning Tool1

Patient Safety Culture Tool2

Worklife Pulse Tool3


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1.3 Overview by Quality Dimensions

Accreditation Canada defines quality in health care using eight dimensions that represent key service elements. Each criterion in the standards is associated with a quality dimension. This table shows the number of criteria related to each dimension that were rated as met, unmet, or not applicable.

Quality Dimension Met Unmet N/A Total

Population Focus (Working with communities to anticipate and meet needs) 23 4 0 27

Accessibility (Providing timely and equitable services) 8 0 0 8

Safety (Keeping people safe)79 5 10 94

Worklife (Supporting wellness in the work environment) 53 3 0 56

Client-centred Services (Putting clients and families first) 27 2 1 30

Continuity of Services (Experiencing coordinated and seamless services) 10 0 0 10

Effectiveness (Doing the right thing to achieve the best possible results) 148 15 3 166

Efficiency (Making the best use of resources)23 1 0 24

Total 371 30 14 415


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1.4 Overview by Standards

The Qmentum standards identify policies and practices that contribute to high quality, safe, and effectively managed care. Each standard has associated criteria that are used to measure the organization's compliance with the standard.

System-wide standards address quality and safety at the organizational level in areas such as governance and leadership. Population-specific and service excellence standards address specific populations, sectors, and services. The standards used to assess an organization's programs are based on the type of services it provides.

This table shows the sets of standards used to evaluate the organization's programs and services, and the number and percentage of criteria that were rated met, unmet, or not applicable during the on-site survey.

Accreditation decisions are based on compliance with standards. Percent compliance is calculated to the decimal and not rounded.

Standards SetMet Unmet N/A

High Priority Criteria *

# (%) # (%) #

Met Unmet N/A

Other Criteria

# (%) # (%) #

Met Unmet N/A

Total Criteria(High Priority + Other)

# (%) # (%) #

Governance 43(97.7%)

1(2.3%)

0 33(97.1%)

1(2.9%)

0 76(97.4%)

2(2.6%)

0

Leadership 42(93.3%)

3(6.7%)

1 78(92.9%)

6(7.1%)

1 120(93.0%)

9(7.0%)

2

Customized Infection Prevention and Control

31(93.9%)

2(6.1%)

4 10(90.9%)

1(9.1%)

1 41(93.2%)

3(6.8%)

5

Customized Managing Medications

24(100.0%)

0(0.0%)

2 11(100.0%)

0(0.0%)

0 35(100.0%)

0(0.0%)

2

Substance Abuse and Problem Gambling Services

24(92.3%)

2(7.7%)

1 60(84.5%)

11(15.5%)

0 84(86.6%)

13(13.4%)

1

164(95.3%)

8(4.7%)

8 192(91.0%)

19(9.0%)

2 356(93.0%)

27(7.0%)

10Total

* Does not includes ROP (Required Organizational Practices)


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1.5 Overview by Required Organizational Practices

A Required Organizational Practice (ROP) is an essential practice that an organization must have in place to enhance client safety and minimize risk. Each ROP has associated tests for compliance, categorized as major and minor. All tests for compliance must be met for the ROP as a whole to be rated as met.

This table shows the ratings of the applicable ROPs.

Required Organizational Practice Overall rating Test for Compliance Rating

Major Met Minor Met

Patient Safety Goal Area: Safety Culture

Adverse Events Disclosure(Leadership)

Met 3 of 3 0 of 0

Adverse Events Reporting(Leadership)

Met 1 of 1 1 of 1

Client Safety Quarterly Reports(Leadership)

Met 1 of 1 2 of 2

Client Safety Related Prospective Analysis(Leadership)

Unmet 0 of 1 0 of 1

Patient Safety Goal Area: Communication

Client And Family Role In Safety(Substance Abuse and Problem Gambling Services)

Met 2 of 2 0 of 0

Dangerous Abbreviations(Customized Managing Medications)

Met 4 of 4 3 of 3

Information Transfer(Substance Abuse and Problem Gambling Services)

Met 2 of 2 0 of 0

Medication Reconciliation As An Organizational Priority(Leadership)

Met 4 of 4 0 of 0

Medication Reconciliation At Admission(Substance Abuse and Problem Gambling Services)

Met 4 of 4 1 of 1


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Required Organizational Practice Overall rating Test for Compliance Rating

Major Met Minor Met

Patient Safety Goal Area: Communication

Medication Reconciliation at Transfer or Discharge(Substance Abuse and Problem Gambling Services)

Met 4 of 4 1 of 1

Two Client Identifiers(Customized Managing Medications)

Met 1 of 1 0 of 0

Two Client Identifiers(Substance Abuse and Problem Gambling Services)

Met 1 of 1 0 of 0

Patient Safety Goal Area: Worklife/Workforce

Client Safety Plan(Leadership)

Met 2 of 2 2 of 2

Client Safety: Education And Training(Leadership)

Met 1 of 1 0 of 0

Preventive Maintenance Program(Leadership)

Met 3 of 3 1 of 1

Workplace Violence Prevention(Leadership)

Unmet 4 of 5 3 of 3

Patient Safety Goal Area: Infection Control

Hand Hygiene Audit(Customized Infection Prevention and Control)

Unmet 0 of 1 0 of 2

Hand Hygiene Education And Training(Customized Infection Prevention and Control)

Met 2 of 2 0 of 0


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The surveyor team made the following observations about the organization's overall strengths, opportunities for improvement, and challenges.

1.6 Summary of Surveyor Team Observations

Portage is a bilingual non-profit organization offering a continuum of services to people with substance-abuse problems and concomitant disorders. Founded in 1970, Portage operates substance abuse rehabilitation centres in Quebec, Ontario, New Brunswick, and British Columbia. It provides residential and non-residential services. The clinical programs are designed for adults, mothers with children, and mentally ill chemical abusers.

The organization is participating in its second accreditation cycle under the Qmentum program. Since its last accreditation survey in 2010, Portage has made efforts to respond to Accreditation Canada’s recommendations, especially those related to safety and medication management. Consequently, the organization was well prepared for the recent Accreditation Canada survey at each of its eight sites. In some centres, young residents were involved in the tours, which enabled the surveyors to assess the physical environment and to receive a special presentation about the clinical program from members of the therapeutic community. Portage’s Board of Directors consists of a group of people dedicated and committed to the organization and its strategic vision. The Chairman has held this position since 1970, and the Executive Director has been there since 1979. When board members are due for re-appointment, the organization is careful to ensure representation from various types of experts, and the continuing participation of experienced members on the board.

The board of directors supervises the organization’s strategic planning process. The 2013-2016 strategic plan was recently adopted following consultations with internal and external bodies. The board is commended for an excellent analysis of the environment in which Portage works; the report clearly identifies the changes and new challenges that the organization had to take into account during the strategic planning process. The management team consists of representatives from each centre. The members of the management team are passionate about and dedicated to Portage and its program. Communication among the directors is frequent and provides a forum for sharing information and ensuring standardization in the program’s implementation. Several partnerships have been established with community services and government bodies. Portage is encouraged to consolidate its cooperation with external partners to promote better continuity, seamlessness, and coordination of services. This is especially important before and after clients access Portage’s services. In fact, the lack of effective relations in some situations reduces or prevents access to services, and resource utilization is not maximized.

Portage has many dedicated, competent staff members who are responsive to clients’ needs. Staff members have access to training programs and the information required to safely provide care and services to clients. During the survey, the surveyors noted that interactions between the residents and staff members were respectful. Their clinical approach enables them to establish positive therapeutic relations with their clients.

Procedures related to patient safety should be pursued. Dashboards to monitor certain worklife indicators need to be developed. Medication management, infection prevention and control, and emergency response measures are well organized and of a high quality.

Regularly conducted surveys show that clients are extremely satisfied with the services Portage provides. The residents’ committees and the patients’ committees are actively involved in the centres. The members of these committees provide an important service by offering help to families, residents, and clients by handling, for example, dissatisfaction and complaints. The Complaints Commissioner is readily available to handle client complaints about the Quebec-based centres, and his reports are sent to the board of directors in Quebec.

all centres and to forward resultant reports to the board of directors, so the reports can be made available as part of the quality improvement process.

Numerous quality initiatives are conducted within Portage; however, they are not identified as such. Quality improvement initiatives are not always recognized, and information about the initiatives is not always communicated to the entire organization. (That said, some quality indicators have been identified and are monitored, such as client satisfaction.) Not every team at Portage has the same level of understanding of the components of an integrated quality improvement program. Developing an integrated quality improvement plan would result in more standardized and consistent implementation of the plan’s components.

Partial data about Portage’s services are available. However, an integrated management framework for performance must be developed. It must identify performance outcome measures that could help the organization evaluate whether the expected outcomes are actually being achieved. Identifying clinical outcome indicators related to key clinical interventions would help determine the impact of each phase of the clinical program.

The organization is encouraged to make clinical evidence about the programs and services available, and to update these data. Moreover, Portage is urged to partner with university researchers to benefit from their expertise, and to enable steps such as promoting the comparability of data.

It is noteworthy that the organization and staff are dedicated to providing services that are truly going to help people. This was strongly indicated by some residents.


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Portage is encouraged to provide this type of impartial and independent mechanism for handling complaints in all centres and to forward resultant reports to the board of directors, so the reports can be made available as part of the quality improvement process.

Numerous quality initiatives are conducted within Portage; however, they are not identified as such. Quality improvement initiatives are not always recognized, and information about the initiatives is not always communicated to the entire organization. (That said, some quality indicators have been identified and are monitored, such as client satisfaction.) Not every team at Portage has the same level of understanding of the components of an integrated quality improvement program. Developing an integrated quality improvement plan would result in more standardized and consistent implementation of the plan’s components.

Partial data about Portage’s services are available. However, an integrated management framework for performance must be developed. It must identify performance outcome measures that could help the organization evaluate whether the expected outcomes are actually being achieved. Identifying clinical outcome indicators related to key clinical interventions would help determine the impact of each phase of the clinical program.

The organization is encouraged to make clinical evidence about the programs and services available, and to update these data. Moreover, Portage is urged to partner with university researchers to benefit from their expertise, and to enable steps such as promoting the comparability of data.

It is noteworthy that the organization and staff are dedicated to providing services that are truly going to help people. This was strongly indicated by some residents.


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Detailed Required Organizational Practices ResultsSection 2

Each ROP is associated with one of the following patient safety goal areas: safety culture, communication, medication use, worklife/workforce, infection control, or risk assessment.

This table shows each unmet ROP, the associated patient safety goal, and the set of standards where it appears.

Unmet Required Organizational Practice Standards Set

Patient Safety Goal Area: Safety Culture

· Leadership 15.9Client Safety Related Prospective AnalysisThe organization carries out at least one client safety-related prospective analysis and implements appropriate improvements.

Patient Safety Goal Area: Worklife/Workforce

· Leadership 2.10Workplace Violence PreventionThe organization implements a comprehensive strategy to prevent workplace violence.

Patient Safety Goal Area: Infection Control

· Customized Infection Prevention and Control 4.4

Hand Hygiene AuditThe organization evaluates its compliance with accepted hand-hygiene practices.

Detailed Required Organizational Practices Results 9Accreditation Report

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Detailed On-site Survey ResultsSection 3

This section provides the detailed results of the on-site survey. When reviewing these results, it is important to review the service excellence and the system-wide results together, as they are complementary. Results are presented in two ways: first by priority process and then by standards sets.

Accreditation Canada defines priority processes as critical areas and systems that have a significant impact on the quality and safety of care and services. Priority processes provide a different perspective from that offered by the standards, organizing the results into themes that cut across departments, services, and teams.

For instance, the patient flow priority process includes criteria from a number of sets of standards that address various aspects of patient flow, from preventing infections to providing timely diagnostic or surgical services. This provides a comprehensive picture of how patients move through the organization and how services are delivered to them, regardless of the department they are in or the specific services they receive.

During the on-site survey, surveyors rate compliance with the criteria, provide a rationale for their rating, and comment on each priority process.

Priority process comments are shown in this report. The rationale for unmet criteria can be found in the organization's online Quality Performance Roadmap.

See Appendix B for a list of priority processes.

ROP Required Organizational Practice

High priority criterion

INTERPRETING THE TABLES IN THIS SECTION: The tables show all unmet criteria from each set of standards, identify high priority criteria (which include ROPs), and list surveyor comments related to each priority process.

High priority criteria and ROP tests for compliance are identified by the following symbols:

Major ROP Test for Compliance

Minor ROP Test for Compliance

MAJOR

MINOR

Detailed On-site Survey Results 10Accreditation Report

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3.1 Priority Process Results for System-wide Standards

The results in this section are presented first by priority process and then by standards set.

Some priority processes in this section also apply to the service excellence standards. Results of unmet criteria that also relate to services should be shared with the relevant team.

3.1.1 Priority Process: Planning and Service Design

Developing and implementing infrastructure, programs, and services to meet the needs of the populations and communities served

Unmet Criteria High PriorityCriteria

Standards Set: Leadership

The organization's leaders collect or have access to information about the community's health status, capacities, and health care needs.

5.1

Surveyor comments on the priority process(es)

The organization’s leaders recently developed a 2013-2016 national strategic plan with the participation of internal and external partners. Specific objectives were set out to ensure that the goals in the strategic plan are met.

It is important to develop a communication plan to disseminate the goals and strategic objectives throughout the organization so that all teams’ objectives align with the strategic plan.

It is also important to communicate the strategic plan to Portage’s various partners working in the area of addictions. This might lead to a better understanding of the services provided by Portage and might help improve the referral pathway for clients.

Because of the many changes that have occurred in the organization, several policies and procedures are available but have not yet been adopted. It is important that the policies and procedures on functions, activities, and key systems be recorded in writing, adopted, implemented, and distributed throughout the organization.


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3.1.2 Priority Process: Governance

Meeting the demands for excellence in governance practice.


Standards Set: Governance

The governing body works with the CEO and the organization's leaders to develop an integrated quality improvement plan.

11.2

The governing body demonstrates a commitment to recognizing staff, service providers, volunteers, and students for their quality improvement work.

11.6


Portage’s Board of Directors consists of a group of people dedicated and committed to the organization and its strategic vision. The Chairman has held this position since 1970, and the Executive Director has been there since 1979. Members of Portage’s Board of Governors and Board of Directors are elected for one-year terms. When board members are due for re-appointment, the organization is careful to ensure representation from various types of experts, and the continuing participation of experienced members on the board. Both boards include representatives from Ontario, Atlantic Canada, British Columbia, and Quebec. The board members are very satisfied with their orientation program, and appreciate the visits to the various sites that make up Portage.

The four regional committees (the regional boards) help the board of directors carry out its responsibilities. Ten permanent Portage committees also exist to help the board of directors. The mandate, structure, and operations of each committee are clearly identified; representation by the chairs of the regional boards on the various committees results in ongoing information sharing.

A code of professional ethics and a code of conduct exists and applies to members of the boards, employees, placement students, and volunteers.

The excellent review of governance that the board conducts each year is noteworthy. This review was recently expanded to include a policy on the role of the Chairman and the Executive Director, as well as succession planning for managers. The board of directors oversees the organization’s strategic planning process. The 2013-2016 strategic plan was recently adopted following extensive consultations with internal and external bodies. The board is commended for an excellent analysis of the environment in which Portage works; the report clearly identifies the changes and new challenges that the organization must take into account during the strategic planning process. A review of agendas from the board of directors’ meetings reveals the board’s concern with having access to all the information necessary to fulfil its responsibilities. A program and watchdog committee presents information on safety and quality issues at the board’s meetings.


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3.1.3 Priority Process: Resource Management

Monitoring, administration, and integration of activities involved with the appropriate allocation and use of resources.

The organization has met all criteria for this priority process.


Financial resources are managed extremely carefully at all levels of the organization. Equipment replacement and the equipment procurement process are conducted bearing in mind client needs, safety, and support for service provision. A client-centred approach is evident in the organization’s resource management.

The budget planning process is very structured and forms part of the organization’s regular planning cycle. The general guidelines are determined by the chair of the board of directors, the Executive Director, the Director of Administrative Services and the Controller. In conjunction with the Director of Administrative Services and the Comptroller, the directors and managers actively participate in preparing the annual budget. The finance committee studies the budgets and recommends when they should be submitted to the board of directors for adoption. The board of directors approves the budgets, financial reports, and capital projects following analysis and recommendation by the audit committee.

The policy for the budget process was recently revised and adopted by the board of directors. This policy defines the entire budget planning and monitoring process for the year.

All members of the management team very carefully monitor the use of the organization’s resources. Every month, the directors receive a detailed report providing them with clear information on the use of hours and other expenses for their particular area.

Several projects designed to improve client services and the service environment, were funded by very generous contributions from foundations.


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3.1.4 Priority Process: Human Capital

Developing the human resource capacity to deliver safe, high quality services



The organization implements a comprehensive strategy to prevent workplace violence.

2.10ROP

2.10.4 The organization conducts risk assessments to ascertain the risk of workplace violence.

MAJOR

The organization's leaders identify and monitor process and outcome measures related to worklife and the work environment.

2.12

The organization defines roles and responsibilities for client safety in writing.

10.7

The organization's policies and procedures to monitor performance include how to deal with performance issues in an objective and fair way.

10.11


Human capital is very important for Portage, and by and large, it is clear that Portage takes care of its human capital and resolves relational conflicts with remarkable aptitude (with the same quality used in the field with clients) as situations arise. Procedures related to patient safety need to be reinforced, and dashboards for monitoring certain worklife indicators need to be developed, to enhance the supervision of existing quality objectives.

Employees are monitored, supervised, and regularly evaluated; however, it seems that managers have difficulty making decisions when employees do not comply with regulations or have competency related problems or difficulties.

Portage is strongly urged to finalize and update its organizational charts to more clearly establish the responsibilities of managers and employees in a way that reflects reality.


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3.1.5 Priority Process: Integrated Quality Management

Using a proactive, systematic, and ongoing process to manage and integrate quality and achieve organizational goals and objectives



The organization's leaders, staff, service providers, volunteers, and students are recognized for their quality improvement work.

3.9

The organization carries out at least one client safety-related prospective analysis and implements appropriate improvements.

15.9ROP

15.9.1 At least one prospective analysis has been completed within the past year.

MAJOR

15.9.2 The organization uses information from the analysis to make improvements.

MINOR

The organization's leaders develop and implement an integrated quality improvement plan.

16.1


Since the last accreditation survey, the organization has made efforts to implement the necessary measures to comply with accreditation standards in the area of safety.

A safety committee exists under the leadership of the Director of Administrative Services and consists of at least one representative from each centre. The committee meets four times per year to examine information on risk, health and safety management issues, and information assets. All incidents and accidents are reviewed, and quarterly reports are prepared for the watchdog committee and the board of directors. A safety report is prepared annually and includes an assessment of the objectives established in the previous year and the action plan for the coming year. The organization is to be commended for this initiative.

The organization promotes a culture in which incidents, accidents, and common problems associated with resident and patient safety are reported and disclosed. A policy and process exist for disclosing accidents to residents and patients.

The organization’s teams do not all have the same level of understanding of the components of an integrated quality management program. Some quality indicators have been identified and are monitored, such as client satisfaction. The outcome measures that could help the organization determine whether the expected outcomes are actually being met still have to be identified. Identifying clinical outcome indicators related to key clinical interventions would help the team understand the impact of each phase of the clinical program.

Numerous quality initiatives exist and are conducted by the organization. However, they are not identified as such. Recognition is not always given to these initiatives, and information on the initiatives is not always communicated to the entire organization. Developing an integrated quality improvement plan would result in more standardized and consistent implementation of the plan’s components.


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3.1.6 Priority Process: Principle-based Care and Decision Making

Identifying and decision making regarding ethical dilemmas and problems.



The ethics framework includes a process for reviewing the ethical implications of research activities.

1.10


During the 2010 accreditation survey, the surveyors recommended to the management committee that a formal clinical ethics committee be established; this committee has been established through the central management committee whose agenda contains a standing item on ethical decision making. The management committee continues to support staff members grappling with clinical ethical issues and, if necessary, it consults an ethics specialist. However, it would be worth making this process better known to all staff members.

Staff members can refer to the following documents about the organization’s ethics and culture: Portage Ethics Framework (a professional ethics policy, procedure, and code of conduct for the board of directors, staff members, volunteers, and placement students), and the Portage Governance Review — 2011-2012.

The mission, vision, and values expressed by Portage are primarily found in their intake and information documentation and are also reflected in the words and conduct of the professionals and support staff members who work with the clients. The organization’s philosophy regarding recovery supports the various therapeutic methods made available to meet client needs.

Portage also collaborates on evaluation research projects that do not require the approval of a research ethics committee, which is currently dissolved. The ethics committee will be established at a later date in preparation for future research projects.


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3.1.7 Priority Process: Communication

Communicating effectively at all levels of the organization and with external stakeholders



The organization is deeply concerned about communication in all its forms. Two directors currently support the communications department, a communications committee has been established, a thematic schedule is used to plan and implement events that are often suitable for media publication, newsletters are issued to staff, access to social media is well thought out, and the Portage website is active (annual reports are located there).

In addition focusing on media relations, Portage would certainly benefit from continuing to solidify its linkages with various governments and departments to increase coordination and agreements with existing public services. It should also use a research avenue to publicize its successes within a recognized university framework.


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3.1.8 Priority Process: Physical Environment

Providing appropriate and safe structures and facilities to achieve the organization's mission, vision, and goals



This sector is clearly under control. The physical environment is well thought out, very pleasant (even inviting), and carefully planned based on client needs (except for the West Island location).

The estimates are compared and the one that best meets an identified need is selected; software is being introduced to track maintenance that needs to be performed; several real estate projects are being studied very carefully to determine their feasibility.


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3.1.9 Priority Process: Emergency Preparedness

Planning for and managing emergencies, disasters, or other aspects of public safety



The organization has developed and implemented emergency preparedness plans to ensure users’ safety. Evacuation drills are held regularly at various sites. Staff members ensure that all new residents are aware of the evacuation plans at the intake stage.


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3.1.10 Priority Process: Patient Flow

Assessing the smooth and timely movement of clients and families through service settings



The organization's leaders use information about barriers to client flow to develop a strategy to build the organization's capacity to meet the demand for service and improve client flow throughout the organization.

13.2

The organization evaluates the effectiveness and impact of the client flow strategy.

13.4


Patient flow is in place as soon as new residents are admitted. The main issues are barriers that exist before residents are admitted. At some sites, resident capacity was considerably higher than the number of residents actually living there. For example, at the Keremeos site in British Columbia, 17 residents were admitted to the program, although it has the capacity to take 42 residents in total. Many beds are therefore available to help other young people with drug problems in the British Columbia region but they remain vacant. This situation was explained as a problem extrinsic to Portage that has not yet been successfully resolved. It is strongly recommended that this obstacle be addressed with the appropriate external bodies, including local governments and regional health authorities, so that these sites can more effectively fulfill their mandate of taking in more adolescents and adults in need of support and assistance.


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3.1.11 Priority Process: Medical Devices and Equipment

Obtaining and maintaining machinery and technologies used to diagnose and treat health problems



Portage is commended for the quality of this priority process.


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3.2 Service Excellence Standards Results

The results in this section are grouped first by standards set and then by priority process.

Priority processes specific to service excellence standards are:

Clinical Leadership

Providing leadership and overall goals and direction to the team of people providing services.

Competency

Developing a skilled, knowledgeable, interdisciplinary team that can manage and deliver effective programs and services

Episode of Care

Providing clients with coordinated services from their first encounter with a health care provider through their last contact related to their health issue

Decision Support

Using information, research, data, and technology to support management and clinical decision making

Impact on Outcomes

Identifying and monitoring process and outcome measures to evaluate and improve service quality and client outcomes

Medication Management

Using interdisciplinary teams to manage the provision of medication to clients

Infection Prevention and Control

Implementing measures to prevent and reduce the acquisition and transmission of infection among staff, service providers, clients, and families

3.2.1 Standards Set: Customized Infection Prevention and Control


Priority Process: Infection Prevention and Control

The organization provides clients and families with information and education about preventing infections in a format that is easy to understand.

2.1

Information provided to clients and families is documented in the client health record.

2.3

The organization evaluates its compliance with accepted hand-hygiene practices.

4.4 ROP


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4.4.1 The organization audits its compliance with hand hygiene practices.

MAJOR

4.4.2 The organization shares results from the audits with staff, service providers, and volunteers.

MINOR

4.4.3 The organization uses the results of the audits to make improvements to its hand hygiene practices.

MINOR

The organization follows national and occupational health and safety guidelines on work restrictions for staff or volunteers with transmissible infections.

5.2


Priority Process: Infection Prevention and Control

With the arrival of a new nursing director, it will be easy for the organization to use targeted procedures to complete an already sustainable structure for infection prevention, especially because the nurses already provide exemplary monitoring and vigilance in the various centres.


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3.2.2 Standards Set: Customized Managing Medications


Priority Process: Medication Management



Priority Process: Medication Management

The organization does not have on-site pharmacies; it is served by the community's pharmacies. Various protocols are made available to staff members in order to appropriately manage the administration and distribution of medications as well as the risks. These include a health care manual and protocols, including a policy and procedure on medication management, a protocol on updating known medication reactions in patients, a protocol on medical emergency measures, medication reconciliation and the distribution of medications, a poster of the abbreviations to use for prescriptions and finally, the management of biomedical waste.

Medications are dispensed using the Dispill system; the medication cart stays in the nurses' room. The double identification required for medication management is met. Staff members who distribute medication in the evening have access to the health care manual, which outlines clinical problems. The MAR indicates allergies and current or past adverse reactions of the patient.

Training is planned for non-medical staff regarding the distribution of medications. With regard to the teaching provided to patients, information is recorded in the patient’s file, and the nurse uses information brochures for this activity as needed.

All criteria are met in the medication management standards; however, caution must be still be exercised, especially if there is staff turnover. Moreover, all sites must use the same form for medication reconciliation. Regarding medication-related incidents, based on the organization's analysis, failure to administer a medication was identified as an issue; an action plan has been developed to deal with this situation.


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3.2.3 Standards Set: Substance Abuse and Problem Gambling Services


Priority Process: Clinical Leadership

The team collects information about its clients and the community.1.1

The team uses information it collects about clients and the community to define the scope of its services and set priorities when multiple service needs are identified.

1.2

The team works together to develop goals and objectives.2.1

The team's goals and objectives for its substance abuse and problem gambling services are measurable and specific.

2.2

Priority Process: Competency

The organization provides sufficient workspace to support interdisciplinary team functioning and interaction.

3.5

The interdisciplinary team follows a formal process to regularly evaluate its functioning, identify priorities for action, and make improvements.

3.7

Priority Process: Episode of Care

The team responds to client and family complaints in an open, fair, and timely way.

8.10

Priority Process: Decision Support

The team has a process to access, review and select which evidence-based guidelines it will use.

14.1

The team reviews its guidelines to make sure they are up-to-date and reflect current research and best practice information.

14.2

The team's process includes seeking input from staff and service providers about the applicability of the guidelines and their ease of use.

14.3

Priority Process: Impact on Outcomes

The team shares benchmark and best practice information with its partners and other organizations.

14.5

The team identifies and monitors process and outcome measures for its substance abuse and problem gambling services.

16.1

The team compares its results with other similar interventions, programs, or organizations.

16.3


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Priority Process: Clinical Leadership

Portage’s clinical program has been formalized for many years. Steps are being taken to strengthen its processes and the uniformity between the various sites. For example, there are discussions between those in charge of admission (or reintegration) and nursing care; this is being done to improve the standardization of their respective programs and processes.

The program is designed to provide continuity to support clients after a stay and during their return to a life that includes positive activities. This aspect of the program is a strength and should be continued and consolidated.

Several collaboration mechanisms exist to ensure that service provision is complementary in terms of all of the services required by clients. For example, there are linkages with the Children’s Hospital for the Mother and Child Program or the Adolescent Program, with the Douglas Mental Health University Institute for people with concomitant disorders, and childcare centres have integrated programming. This also results in work reintegration or schooling activities.

At some sites, a basic operational plan with indicators has been developed or is in the process of being developed for the site’s director and is aligned with Portage’s strategic plan.

Mandatory complementary processes require more specific development of clinical processes. For example, inspection or certification measures, such as those for the Elora site, which must already meet the requirements described in various Government of Ontario bodies’ reports (e.g., the Ministry of Children and Youth Services, Youth Justice Division – compliance requirements 2012) already provide opportunities for the teams’ involvement in developing objectives, their implementation and evaluation. Portage is encouraged to involve the members of its local teams more directly and formally in defining services given the changing needs and issues among both adults and adolescents.

Portage is also encouraged to complete the operational planning process with the teams. This has just been started as a result of the transparency desired by several departments [e.g., Mother and Child, MICA, Adolescents].

Portage is also encouraged to consolidate its cooperation with partners to promote better continuity and coordination of services, especially before and after accessing Portage’s services, and particularly when people come from remote areas.

Placement students and volunteers are accepted on a regular basis; this is a strategic way of recruiting staff members who can and want to work with this client group.

Priority Process: Competency

Portage delivers its services in a structured manner using a rigorous approach adopted by a multidisciplinary team whose members' roles are defined and evolve based on the treatment phase, with a view to maintaining continuity. For example, the admitting officer is there in the beginning and gradually becomes less involved, while the reintegration officer becomes increasingly involved over the course of the program.

continually adjusted as part of an improvement process.

Significant attention is given to orientation and specific training (e.g., access to a degree in addiction treatment provided by the Université de Sherbrooke). This also results in periodic training based on client needs, which happens during the weekly and monthly meetings of group supervisory staff. Training in crisis intervention is also provided (OMEGA, NAPPI, ALPHA).

Particular (and very significant) attention is given to individual and group supervision, as well as to staff performance appraisals and the identification of staff needs. This is noteworthy, and the teams are encouraged to continue this practice.

The teams are encouraged to implement a structured process to evaluate their operations and thus make improvements, in order to evaluate them in more depth than the existing informal discussions during team meetings.

Professional credentials, training (e.g., WHMIS, policies and procedures, safety, emergency procedures, including evacuation drills, CPR, violence management) and the annual evaluation of the staff members’ contributions were in the reviewed employee files.

Staff members are very dedicated; they are invested in clients and the Portage organization. This is evident both in their actions and interactions. This also results in excellent availability (e.g., the person in charge of facility maintenance is available 24-7, as are some nurses and physicians).

To foster a positive worklife balance with family or training obligations, work schedules are prepared to the satisfaction of employees. It was noted that there is no compulsory overtime for Portage’s professionals.


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The team members’ communication processes around the residents are clear and effective. They are continually adjusted as part of an improvement process.

Significant attention is given to orientation and specific training (e.g., access to a degree in addiction treatment provided by the Université de Sherbrooke). This also results in periodic training based on client needs, which happens during the weekly and monthly meetings of group supervisory staff. Training in crisis intervention is also provided (OMEGA, NAPPI, ALPHA).

Particular (and very significant) attention is given to individual and group supervision, as well as to staff performance appraisals and the identification of staff needs. This is noteworthy, and the teams are encouraged to continue this practice.

The teams are encouraged to implement a structured process to evaluate their operations and thus make improvements, in order to evaluate them in more depth than the existing informal discussions during team meetings.

Professional credentials, training (e.g., WHMIS, policies and procedures, safety, emergency procedures, including evacuation drills, CPR, violence management) and the annual evaluation of the staff members’ contributions were in the reviewed employee files.

Staff members are very dedicated; they are invested in clients and the Portage organization. This is evident both in their actions and interactions. This also results in excellent availability (e.g., the person in charge of facility maintenance is available 24-7, as are some nurses and physicians).

To foster a positive worklife balance with family or training obligations, work schedules are prepared to the satisfaction of employees. It was noted that there is no compulsory overtime for Portage’s professionals.

Priority Process: Episode of Care

The clinical processes are implemented and designed to meet the needs of people who are admitted on a voluntary basis as part of a structured access, eligibility, and assessment process that can also provide the flexibility required to meet individual needs. Many examples provided by the teams (e.g., Mother and Child, MICA, West Island, etc.) are very good illustrations of this empathy and this necessity to bend the rules in order to serve people better. The orientation and integration with peer involvement are also evidence of this care and concern.

The patient manual also illustrates the desire to provide comprehensive information. The time taken to explain it to residents also reflects this desire.

All clients have their own treatment plan based on an assessment of the problem from a biopsychosocial perspective. This plan is signed by the client. Portage is encouraged to consider the systematic use of a suicide risk assessment matrix on admission.

The development of the treatment plan, its regular review, and the involvement of the client and the client’s loved ones throughout the process show the importance of the follow-up conducted with the person, including their progress as part of the therapeutic community. Special attention is paid to transition periods between the various phases, and adjustments may be made.

The medication management procedure is clear and known.

"Male phase 2 groups," for which the objectives and activities are clearly described).

The introduction of a healthy eating initiative is another example of the concern to provide a comprehensive response to needs.Whenever possible, the participation and involvement of families during the entire process is encouraged through specific activities offered to them. However, Portage is encouraged to be more proactive in strengthening the participation of families, especially when they are from remote areas.

During the survey, the surveyors noted that interactions between the residents and professionals were respectful. There is a concern to establish a therapeutic relationship with clients.

Processes for handling dissatisfaction and complaints are a concern. Portage is encouraged to provide an impartial and independent complaint-processing mechanism at all sites and to forward the reports so they can be made available as part of the quality improvement process.

The academic program available to adolescents is noteworthy, because it responds to the needs of clients who require this service. The instructors are available for recreational and educational activities; this is all provided with a view to achieving recovery.

Depending on the service providers and the youths to whom they offer services, the adolescents may continue their education after their stay.

Teams are encouraged to finalize the implementation of Global Appraisal of Individual Needs (GAIN) as a clinical instrument used in the processes to complete clinical procedures.


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The programs are defined and provide tools for the service providers and clients (e.g., "Male inductions" and "Male phase 2 groups," for which the objectives and activities are clearly described).

The introduction of a healthy eating initiative is another example of the concern to provide a comprehensive response to needs.Whenever possible, the participation and involvement of families during the entire process is encouraged through specific activities offered to them. However, Portage is encouraged to be more proactive in strengthening the participation of families, especially when they are from remote areas.

During the survey, the surveyors noted that interactions between the residents and professionals were respectful. There is a concern to establish a therapeutic relationship with clients.

Processes for handling dissatisfaction and complaints are a concern. Portage is encouraged to provide an impartial and independent complaint-processing mechanism at all sites and to forward the reports so they can be made available as part of the quality improvement process.

The academic program available to adolescents is noteworthy, because it responds to the needs of clients who require this service. The instructors are available for recreational and educational activities; this is all provided with a view to achieving recovery.

Depending on the service providers and the youths to whom they offer services, the adolescents may continue their education after their stay.

Teams are encouraged to finalize the implementation of Global Appraisal of Individual Needs (GAIN) as a clinical instrument used in the processes to complete clinical procedures.

Priority Process: Decision Support

Clinical information is readily available to service providers, in some cases as electronic medical records. Confidentiality is maintained when sending information, especially medical records. The nurses have implemented a mechanism for sending a summary of information on medications not to be administered as part of treatment at Portage, without however revealing medical diagnoses.

A records quality management process was implemented and helps guarantee compliance with clinical processes and their timetables.

Portage is encouraged to take action on a recommendation from the last accreditation survey and ensure that there is only one record for each patient.

In relation to greater involvement in defining services and objectives, the teams are encouraged to refer to the evidence-based guidelines. The Portage website provides a list of best practices (http://www.portage.ca/drug-addiction-rehabilitation-best-practices), but no references are cited.

The departments involved are encouraged to make this evidence available to the teams and to collect, update, and validate this evidence with the help of service providers and users.

The information technology infrastructure could be used to facilitate access to this evidence by members of various teams.


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Priority Process: Impact on Outcomes

The risk and adverse event management processes are known and analysed, and are thus helpful in terms of improving the quality of services. For example, corrections were made following a series of incidents related to the medication in the West Island adolescent program, and improvements were made to the physical environment for the Mother and Child program to provide better protection for the children (e.g., power outlet covers, door hinge protectors, etc.). Safety training programs are offered to residents. Some are very structured (e.g., housekeeping and kitchen work program in Lac Écho). Improvement plans are completed (e.g., Elora).

The teams obtain the viewpoint of residents on a regular basis, in an interactive way, especially through the residents' committees. The teams then adjust the services and settings accordingly. Portage is encouraged to continue this practice, particularly in conjunction with the patients' committee.

However, these initiatives are not systematic for all aspects of the programs. Outcome and impact evaluation is perceived and understood differently and can be subject to debate. Few data are available to the teams on clients, success, etc. These elements are also understood in different ways. Incomplete information on the impact of programs is available on the website (http://www.portage.ca/research-drug-addiction-therapy). Evaluation of the Mother and Child program has been completed, but has not yet been disseminated.

Over the years, programs have been modified to meet people's needs more effectively (e.g., differentiating between services for men and women, the adolescent program). This process was often completed in a rather empirical and pragmatic manner. In another case—the Mother and Child program—a formal process was implemented that is associated with an evaluation program.

To continue to consolidate its leadership, Portage is encouraged to develop an integrated strategy for evaluating the clinical and administrative performance of its programs, and to make known the results to patients, patients’ family members/friends, service providers, and partners. Portage is also encouraged to integrate such data to more clearly define programs and services. The work initiated and conducted by the research department is moving in this direction and is noteworthy.

Given its mission, acquired expertise, and the specific nature of the approaches and programs, Portage is urged to partner with university researchers to benefit from their expertise, thereby promoting the comparability of data.


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Instrument ResultsSection 4

As part of Qmentum, organizations administer instruments. Qmentum includes three instruments (or questionnaires) that measure governance functioning, patient safety culture, and quality of worklife. They are completed by a representative sample of clients, staff, senior leaders, board members, and other stakeholders.

4.1 Governance Functioning Tool

The Governance Functioning Tool enables members of the governing body to assess board structures and processes, provide their perceptions and opinions, and identify priorities for action. It does this by asking questions about:

• Board composition and membership • Scope of authority (roles and responsibilities) • Meeting processes • Evaluation of performance

Accreditation Canada provided the organization with detailed results from its Governance Functioning Tool prior to the on-site survey through the client organization portal. The organization then had the opportunity to address challenging areas.

• Data collection period: May 1, 2012 to November 11, 2012

• Number of responses: 14

Governance Functioning Tool Results

% Disagree % Neutral % Agree

Organization Organization Organization

* CanadianAverage

%Agree

1 We regularly review, understand, and ensure compliance with applicable laws, legislation and regulations.

0 0 100 92

2 Governance policies and procedures that define our role and responsibilities are well-documented and consistently followed.

0 7 93 95

3 We have sub-committees that have clearly-defined roles and responsibilities.

0 0 100 96

4 Our roles and responsibilities are clearly identified and distinguished from those delegated to the CEO and/or senior management. We do not become overly involved in management issues.

0 0 100 93

5 We each receive orientation that helps us to understand the organization and its issues, and supports high-quality decision-making.

0 14 86 92

Instrument Results 30Accreditation Report

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* CanadianAverage

%Agree

6 Disagreements are viewed as a search for solutions rather than a “win/lose”.

8 0 92 93

7 Our meetings are held frequently enough to make sure we are able to make timely decisions.

0 0 100 98

8 Individual members understand and carry out their legal duties, roles and responsibilities, including sub-committee work (as applicable).

0 0 100 95

9 Members come to meetings prepared to engage in meaningful discussion and thoughtful decision-making.

7 0 93 94

10 Our governance processes make sure that everyone participates in decision-making.

7 7 86 93

11 Individual members are actively involved in policy-making and strategic planning.

0 7 93 90

12 The composition of our governing body contributes to high governance and leadership performance.

0 14 86 92

13 Our governing body’s dynamics enable group dialogue and discussion. Individual members ask for and listen to one another’s ideas and input.

7 0 93 95

14 Our ongoing education and professional development is encouraged.

0 21 79 86

15 Working relationships among individual members and committees are positive.

0 0 100 96

16 We have a process to set bylaws and corporate policies.

7 0 93 95

17 Our bylaws and corporate policies cover confidentiality and conflict of interest.

0 14 86 96

18 We formally evaluate our own performance on a regular basis.

14 7 79 76

19 We benchmark our performance against other similar organizations and/or national standards.

14 21 64 68

20 Contributions of individual members are reviewed regularly.

14 14 71 66


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* CanadianAverage

%Agree

21 As a team, we regularly review how we function together and how our governance processes could be improved.

21 7 71 77

22 There is a process for improving individual effectiveness when nonperformance is an issue.

14 29 57 59

23 We regularly identify areas for improvement and engage in our own quality improvement activities.

7 21 71 82

24 As a governing body, we annually release a formal statement of our achievements that is shared with the organization’s staff as well as external partners and the community.

7 7 86 84

25 As individual members, we receive adequate feedback about our contribution to the governing body.

7 29 64 68

26 Our chair has clear roles and responsibilities and runs the governing body effectively.

0 14 86 94

27 We receive ongoing education on how to interpret information on quality and patient safety performance.

0 21 79 86

28 As a governing body, we oversee the development of the organization’s strategic plan.

0 7 93 96

29 As a governing body, we hear stories about clients that experienced harm during care.

7 36 57 83

30 The performance measures we track as a governing body give us a good understanding of organizational performance.

0 14 86 91

31 We actively recruit, recommend and/or select new members based on needs for particular skills, background, and experience.

7 7 86 91

32 We have explicit criteria to recruit and select new members.

7 21 71 83

33 Our renewal cycle is appropriately managed to ensure continuity on the governing body.

21 0 79 88


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* CanadianAverage

%Agree

34 The composition of our governing body allows us to meet stakeholder and community needs.

0 14 86 93

35 Clear written policies define term lengths and limits for individual members, as well as compensation.

23 15 62 92

36 We review our own structure, including size and sub-committee structure.

7 14 79 87

37 We have a process to elect or appoint our chair. 14 29 57 92

*Canadian average: Percentage of Accreditation Canada client organizations that completed the instrument from July to December, 2012 and agreed with the instrument items.


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4.2 Patient Safety Culture Tool

Organizational culture is widely recognized as a significant driver in changing behavior and expectations in order to increase safety within organizations. A key step in this process is the ability to measure the presence and degree of safety culture. This is why Accreditation Canada provides organizations with the Patient Safety Culture Tool, an evidence-informed questionnaire that provides insight into staff perceptions of patient safety. This tool gives organizations an overall patient safety grade and measures a number of dimensions of patient safety culture.

Results from the Patient Safety Culture Tool allow the organization to identify strengths and areas for improvement in a number of areas related to patient safety and worklife.

Accreditation Canada provided the organization with detailed results from its Patient Safety Culture Tool prior to the on-site survey through the client organization portal. The organization then had the opportunity to address areas for improvement. During the on-site survey, surveyors reviewed progress made in those areas.

• Data collection period: May 1, 2012 to October 4, 2012


• Minimum responses rate (based on the number of eligible employees): 168


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0

10

20

30

40

50

60

70

80

90

100

Perc

enta

ge P

osi

tive (

%)

Senior leadershipsupport for safety(valuing safety)

Patient safety learningculture

Supervisory leadershipsupport for safety

Communicationbarriers/talking about

errors

Overall perception ofpatient safety

81% 64% 81% 64% 77%

65% 57% 71% 53% 67%


* Canadian Average

Portage

Legend

Patient Safety Culture: Results by Patient Safety Culture Dimension


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4.3 Worklife Pulse Tool

Accreditation Canada helps organizations create high quality workplaces that support workforce wellbeing and performance. This is why Accreditation Canada provides organizations with the Worklife Pulse Tool, an evidence-informed questionnaire that takes a snapshot of the quality of worklife.

Organizations can use results from the Worklife Pulse Tool to identify strengths and gaps in the quality of worklife, engage stakeholders in discussions of opportunities for improvement, plan interventions to improve the quality of worklife and develop a clearer understanding of how quality of worklife influences the organization's capacity to meet its strategic goals. By taking action to improve the determinants of worklife measured in the Worklife Pulse tool, organizations can improve outcomes.

• Data collection period: May 1, 2012 to September 30, 2012


• Minimum responses rate (based on the number of eligible employees): 164

Accreditation Canada provided the organization with detailed results from its Worklife Pulse Tool prior to the on-site survey through the client organization portal. The organization then had the opportunity to address areas for improvement. During the on-site survey, surveyors reviewed progress made in those areas.


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0

10

20

30

40

50

60

70

80

90

100

Perc

enta

ge P

osi

tive (

%)

Organiza-tional

communi-cation

Supervi-sion

Work areacommuni-

cation

Jobcontrol

Roleclarity

55%

Decisionmakinginvolve-

ment

Jobdemand

68% 79% 75% 84% 56% 46%

54% 65% 74% 70% 84% 55% 49%


Trust

61%

69%

Learningenviron-

ment

Safeenviron-

ment

Worklifebalance

80%

69% 76%

90%

67%

67%

* Canadian Average

Portage

Legend

Worklife Pulse Tool: Results of Work Environment


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QmentumAppendix A

Health care accreditation contributes to quality improvement and patient safety by enabling a health organization to regularly and consistently assess and improve its services. Accreditation Canada's Qmentum accreditation program offers a customized process aligned with each client organization's needs and priorities.

As part of the Qmentum accreditation process, client organizations complete self-assessment questionnaires, submit performance measure data, and undergo an on-site survey during which trained peer surveyors assess their services against national standards. The surveyor team provides preliminary results to the organization at the end of the on-site survey. Accreditation Canada reviews these results and issues the Accreditation Report within 10 business days.

An important adjunct to the Accreditation Report is the online Quality Performance Roadmap, available to client organizations through their portal. The organization uses the information in the Roadmap in conjunction with the Accreditation Report to ensure that it develops comprehensive action plans.

Throughout the four-year cycle, Accreditation Canada provides ongoing liaison and support to help the organization address issues, develop action plans, and monitor progress.

Following the on-site survey, the organization uses the information in its Accreditation Report and Quality Performance Roadmap to develop action plans to address areas identified as needing improvement. The organization provides Accreditation Canada with evidence of the actions it has taken to address these required follow ups.

Five months after the on-site survey, Accreditation Canada evaluates the evidence submitted by the organization. If the evidence shows that a sufficient percentage of previously unmet criteria are now met, a new accreditation decision that reflects the organization's progress may be issued.

Evidence Review and Ongoing Improvement

Action Planning

Qmentum 38Accreditation Report

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Priority ProcessesAppendix B

Priority processes associated with system-wide standards

Priority Process Description

Communication Communicating effectively at all levels of the organization and with external stakeholders

Emergency Preparedness Planning for and managing emergencies, disasters, or other aspects of public safety

Governance Meeting the demands for excellence in governance practice.

Human Capital Developing the human resource capacity to deliver safe, high quality services

Integrated Quality Management

Using a proactive, systematic, and ongoing process to manage and integrate quality and achieve organizational goals and objectives

Medical Devices and Equipment

Obtaining and maintaining machinery and technologies used to diagnose and treat health problems

Patient Flow Assessing the smooth and timely movement of clients and families through service settings

Physical Environment Providing appropriate and safe structures and facilities to achieve the organization's mission, vision, and goals

Planning and Service Design Developing and implementing infrastructure, programs, and services to meet the needs of the populations and communities served

Principle-based Care and Decision Making

Identifying and decision making regarding ethical dilemmas and problems.

Resource Management Monitoring, administration, and integration of activities involved with the appropriate allocation and use of resources.

Priority processes associated with population-specific standards


Chronic Disease Management Integrating and coordinating services across the continuum of care for populations with chronic conditions

Population Health and Wellness

Promoting and protecting the health of the populations and communities served, through leadership, partnership, innovation, and action.

Priority Processes 39Accreditation Report

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Priority processes associated with service excellence standards


Blood Services Handling blood and blood components safely, including donor selection, blood collection, and transfusions

Clinical Leadership Providing leadership and overall goals and direction to the team of people providing services.

Competency Developing a skilled, knowledgeable, interdisciplinary team that can manage and deliver effective programs and services

Decision Support Using information, research, data, and technology to support management and clinical decision making

Diagnostic Services: Imaging Ensuring the availability of diagnostic imaging services to assist medical professionals in diagnosing and monitoring health conditions

Diagnostic Services: Laboratory

Ensuring the availability of laboratory services to assist medical professionals in diagnosing and monitoring health conditions

Episode of Care Providing clients with coordinated services from their first encounter with a health care provider through their last contact related to their health issue

Impact on Outcomes Identifying and monitoring process and outcome measures to evaluate and improve service quality and client outcomes

Infection Prevention and Control

Implementing measures to prevent and reduce the acquisition and transmission of infection among staff, service providers, clients, and families

Medication Management Using interdisciplinary teams to manage the provision of medication to clients

Organ and Tissue Donation Providing organ donation services for deceased donors and their families, including identifying potential donors, approaching families, and recovering organs

Organ and Tissue Transplant Providing organ transplant services, from initial assessment of transplant candidates to providing follow-up care to recipients

Organ Donation (Living) Providing organ donation services for living donors, including supporting potential donors to make informed decisions, conducting donor suitability testing, and carrying out donation procedures

Point-of-care Testing Services

Using non-laboratory tests delivered at the point of care to determine the presence of health problems


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Primary Care Clinical Encounter

Providing primary care in the clinical setting, including making primary care services accessible, completing the encounter, and coordinating services

Surgical Procedures Delivering safe surgical care, including preoperative preparation, operating room procedures, postoperative recovery, and discharge


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