On-site Survey DebriefingCASA Child, Adolescent and
Family Mental Health21/10/2013 - 24/10/2013
On-site Survey DebriefingCASA Child, Adolescent and
Family Mental Health21/10/2013 - 24/10/2013
© Accreditation Canada/Agrément Canada
The On-Site SurveyThe On-Site Survey
A comprehensive review of governance, leadership, clinical programs and services
Incorporates multiple sources of evidence Observations from tours and direct care
provision Discussions with staff, clients, families, board,
community partners, and stakeholders Review of documentation
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Overview of the On-Site Survey Overview of the On-Site Survey
21/10/2013 - 24/10/2013 Genevieve Corbin Doreen Fey Kevin Hayes
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Preliminary ResultsPreliminary Results
The results presented here are preliminary.
Results will be reviewed by Accreditation Canada for internal consistency. Therefore, it is recommended that these results be reserved for internal use.
The Accreditation Report, issued by Accreditation Canada within 10 days, will provide final results and the accreditation decision.
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Overall StrengthsOverall Strengths
Innovation ie new Front Door Services
Effective Outreach
Generosity of Spirit
Organizations Report Card and Targets
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Overall Areas for ImprovementOverall Areas for Improvement
Leadership Development
Infection Prevention and Control practices
Implement medication rec fully across programs
Policy Development cycle
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Overview by Quality DimensionOverview by Quality Dimension
Quality Dimension Met
Unmet
N/A Total
Population Focus (Working with communities to anticipate and meet needs) 31 6 0 37
Accessibility (Providing timely and equitable services) 18 1 0 19
Safety (Keeping people safe) 104 8 20 132
Worklife (Supporting wellness in the work environment) 57 7 1 65
Client-centred Services (Putting clients and families first) 50 0 1 51
Continuity of Services (Experiencing coordinated and seamless services) 12 0 0 12
Effectiveness (Doing the right thing to achieve the best possible results) 182 33 15 230
Efficiency (Making the best use of resources) 26 1 0 27
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Overview by Standard SectionOverview by Standard Section
Standard Section Met Unmet
N/A Total
Governance 72 6 0 78
Leadership 112 27 1 140
Infection Prevention and Control 54 17 30 101
Customized Managing Medications 46 1 5 52
Community-Based Mental Health Services and Supports Standards 134 1 0 135
Telehealth Services 62 4 1 67
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High-priority criteria focus on …High-priority criteria focus on …
Patient safety Ethics Risk management Quality improvement
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Patient safetyPatient safety
Strengths Client and family education Hand Hygiene Audits
Areas for improvement
Report on progress to staff, leaders and Board
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EthicsEthics
Strengths Staff survey to understand the importance of
ethics process Research ethics framework has been
developed
Areas for improvement: Complete the action plan Develop framework
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Risk managementRisk management
Strengths Job hazard analysis Health and safety audit
Areas for improvement Complete the risk assessment process Develop risk framework and risk mitigation
plan CASA Center
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Quality improvementQuality improvement
Strengths Focus on consultation during improvement
activities Evaluation at a glance
Areas for improvement Integrate the framework Prioritize improvement projects
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Reaching an accreditation decisionReaching an accreditation decision
Surveyor findings are forwarded to Accreditation Canada
Decision is made by the Accreditation Decision Committee, in collaboration with surveyors as required
Accreditation Decision Committee ensures consistency in application of decision guidelines
Decision guidelines include compliance with standards criteria, Required Organizational Practices, and instrument thresholds
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Accreditation AchievementAccreditation Achievement
Participating in accreditation is a significant achievement
Demonstrates commitment to quality and safety
Best results achieved through continued integration of accreditation into ongoing quality initiatives
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Next StepsNext Steps
Accreditation Report, with accreditation decision, issued within 10 days
Over the next five months, submit evidence of action taken to address gaps
Continue to action opportunities for improvement
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Contact usContact us
Accreditation Canada
1150 Cyrville RoadOttawa, ON Canada K1J 7S9
Tel: 1-800-814-7769 or 613-738-3800Fax: 1-800-811-7088 or 613-738-3755
www.accreditation.ca
Accreditation Canada does not accept responsibility for the accuracy of this material if is presented by anyone other than an authorized Accreditation Canada representative.
The leader in raising the bar for health quality
The leader in raising the bar for health quality
Le leader qui hausse la barre en matière de qualité de santéLe leader qui hausse la barre
en matière de qualité de santé
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