CARF Report Template -...

Accreditation Report Quality Improvement Plan & Benchmarking Data

Prepared for Erie St. Clair Community Care Access Centre

Accreditation Decision

Three-Year Accreditation Expiration: June 2015

Organization

Erie St. Clair Community Care Access Centre (ESC CCAC) 712 Richmond Street, Box 306 Chatham, ON N7M 5K4 Canada

Organizational Leadership

Betty Kuchta, B.A, LL.B., Chief Executive Officer Melanie Bucek, M.S.W., Quality Improvement Manager Glenda Maillioux, CGA, Senior Director, Corporate Services

Survey Dates

June 27-29, 2012

Survey Team

Blair Philippi, Administrative Surveyor Brent Selman, Program Surveyor Avanthi Goddard, B.B.A. Hon., Dip Adult Ed., Program Surveyor

Programs/Services Surveyed

Home and Community Services

Services Management Network with Access Centre

Governance Standards Applied

1 Erie St. Clair Community Care Access Centre Accreditation Report

Programs/Services by Location

Erie St. Clair Community Care Access Centre

712 Richmond Street, Box 306 Chatham, ON N7M 5K4 Canada


Services Management Network with Access Centre

Governance Standards Applied

ESC CCAC-Windsor Site

5415 Tecumseh Road East, 2nd Floor Windsor, ON N8T 1C5 Canada


ESC CCAC-Sarnia Site

1150 Pontiac Drive Sarnia, ON N7T 7H9 Canada


Erie St. Clair Community Care Access Centre Accreditation Report 2

Survey Summary

Areas of Strength

Erie St. Clair Community Care Access Centre (ESC CCAC) has strengths in many areas. ♦ ESC CCAC is a high-performing health service provider dedicated to improving the quality of life of

persons served in the area it serves. The board, senior leadership, and staff show an immense loyalty and commitment to putting the person served first. Programs are designed and delivered based on best practices and identified population and geographic needs. Examples include the Geriatric Rapid Response Team and Palliative Care Consultation Team (PCCT). ESC CCAC has been recognized both locally and provincially for its success in these programs and others at the organization.

♦ ESC CCAC has undergone immense change since its beginnings in the late 1990s. ESC CCAC, after amalgamation, worked diligently to integrate operations and develop a model of care that is reflective of the needs of the community. This organization benefits tremendously from the experience of the CEO in the community and her longevity in this position.

♦ ESC CCAC has excellent legal and regulatory policies and processes to support its business functions to operate a large organization across multiple sites. Procurement guidelines and the monitoring of performance of health service providers completed in a proactive fashion and the quarterly meetings and joint agendas are appreciated by agencies outside the organization. The organization also credits its success due to its involvement with the Ontario Association of Community Care Access Centres as this collaborative relationship enables provincial program development and planned implementation.

♦ Governance oversight and accountability are evident in the approach and trust the board has in the CEO. Board members are actively engaged and are aware of their role and continue to seek opportunities to identify strategic needs and resources for the benefit of the community in the Erie St. Clair Local Health Integration Network (LHIN) region.

♦ The culture is warm and inviting. People work collaboratively in a safe and positive environment in Chatham, Sarnia, and Windsor. Human resource and health and safety policies are very well done, and front-line staff appreciates the support and ongoing communications to improve their work lives. Further, staff members shared that the ESC CCAC is their employer of choice, and the best decision they made was to come work here. Senior management and the CEO are to be commended for building that supportive culture over time. In these challenging and stressful times, the organization continues to support staff every day.

♦ The PCCT and the Geriatric Rapid Response Team programs provide professional, specialized resources both to persons served and other service providers in the network. The programs have been initiated to address the unique health needs of the region, and ESC CCAC has responded to its community in a proactive manner using a coordinated approach of specialized services that is unique to community care.

♦ There is a dedicated team assistant role for the programs to ensure consistency in approach and provide a common contact for the service providers and persons served.

♦ The team members for both programs are cognizant of the risk that the persons served have to deal with and have a well-developed on-call system within the specialized services.


Areas for Improvement

ESC CCAC should seek improvement in the following areas.

♦ The organization should engage stakeholders (persons served and contracted health service providers) in the development of its strategic planning by providing opportunities for them to give input regarding its strengths and opportunities.

♦ The organization should conduct a more comprehensive analysis of its accessibility issues that includes providing opportunities for persons served, personnel, and other stakeholders to give input to assist in the identification of barriers and take into consideration any accessibility needs that may hinder full and effective participation on an equal basis with others. All identified barriers should be included in ESC CCAC’s accessibility plan that addresses action for the removal of barriers and time lines for their removal.

♦ ESC CCAC should prepare an accessibility status report that includes progress made in the removal of identified barriers and areas for improvement. The accessibility plan was recently implemented; however, the organization should ensure that it prepares the status report on an annual basis moving forward.

Accreditation Decision

Erie St. Clair Community Care Access Centre has earned a Three-Year Accreditation. On balance, the organization has many strengths as demonstrated by its high level of conformance to the CARF standards, while simultaneously recognizing the areas for improvement. ESC CCAC has sound practices in business processes and policies that support operations and program delivery. Staff is engaged and values the emphasis that management places on human resources and health safety, information management, and information technology. Governance oversight is strategic, and board members seek information about the outcomes of service delivery for persons served in the region. As a business services network providing aging services to its population, the organization has worked closely with its network of providers, reaching and benefiting thousands of seniors. Its mission is evidenced throughout the network and echoed by persons served who are the beneficiaries of an incredibly strong coordination of services. Although some areas for improvement have been identified, it is apparent that the organization is actively working toward meeting all standards and should continue the efforts in place.


Exemplary Conformance

Section 2. Care Process for the Persons Served A. Program/Service Structure ♦ The PCCT is a unique program with a focus to improve access to quality palliative care for persons

served in their preferred setting where possible. The team is composed of a variety of healthcare professionals, including nurse practitioners, resource nurses, an occupational therapist, a social worker, a local physician, and other allied health professionals. The key to the success of the team is the role of the nurse practitioners who have specialized competencies around the issues like the type of cancer that persons served are living with, the pain management techniques and medications required to manage the pain, and the medical resources available in the region. The case management and coordination of a specialized medical need such as this is unique. They are able to respond in a timely manner and to navigate the system for their persons served. Statistics from the past year highlight some of the positive impacts achieved by the PCCT. Between April 1 and October 31, 2010, the PCCT made it possible for 85 percent of end-of-life persons served in Sarnia to die in the home, a significant role of the team that persons served note as a priority. Similarly, part of the PCCT’s function is to avoid emergency room visits for palliative persons served, 286 of which were avoided between April 1 and October 31. This is an amazing program focused on the person served and adds a benefit to the congested local hospitals. The program also addresses the specific health needs of the population of the region and has been recognized by its peers, funders, and government leaders as being unique, innovative, and effective.

Consultation

Section 1. ASPIRE to Excellence® G. Risk Management ♦ It is suggested that ESC CCAC develop a system to roll up risk data specific to persons served in a

simple, meaningful way. ESC CCAC is encouraged to undertake a process for defining the criteria of risk that are consistent across the network, and this information could be used during emergencies. Another purpose of this report is to create suitable action plans and make decisions in real time. A format that is easy to understand for staff could be made to link existing plans and process in performance improvement, accessibility, and financial monitoring.

I. Human Resources ♦ ESC CCAC has highly engaged staff members who are dedicated and loyal to the organization, and

leadership is encouraged to continue to communicate its person-centred approach to staff members and how they can live these values every day.


The following consultation applies to the Services Management Network program area.

Section 2. Network Administration B. Administration Structure and Accountability ♦ ESC CCAC is encouraged to work closely with contracted health service providers to review any

planned changes to service based on financial constraints. The organization has developed a comprehensive plan to address current financial pressures and might consider developing a detailed communication strategy to outline any impacts to care of persons served.

Consultation does not indicate non-conformance to standards, but is offered as a suggestion for further quality improvement.


Standards Conformance This section of the Accreditation Report displays the specific reasons for any partial or non-conformance to standards identified as a result of the survey. The standards listed in this section are addressed in the organization’s Quality Improvement Plan, which can be accessed at customerconnect.carf.org.

Below are the possible reasons for partial or non-conformance to standards, along with an explanation of why each reason is cited.

To receive the information contained in this section in an alternate format, please contact [email protected].

Reason for partial or non-conformance Is cited:

All components not addressed When a standard element requires more than one item, at least one item (but not all) is not in full conformance.

Credentials inadequate When a standard element requires that an individual possess a specific credential or level of credential, the specific credential is not possessed, or the credential possessed is below the specified level.

Data or information necessary to address conformance not collected and/or evaluated

When the issue addressed by the standard element has not been considered and, consequently, the information necessary to address conformance has not been collected and/or evaluated in connection with the issue addressed.

Documentation inadequate When a standard element requires documentation or that documentation contain specific information, the documentation either does not exist or does not contain the specific information.

Effort not comprehensive When a standard element requires an activity to occur, the performance of the activity is insufficient to address the full scope of the activity.

Financial ratio calculation below the median

When the standard element rating is based on the calculation of a specific financial ratio, such ratio is below the 50th percentile.

Forms inadequate When a standard element requires use of a specific form or that the form contain specific information, the form is not used or does not contain the specific information.

Frequency inadequate When a standard element requires that an activity occur with a specific frequency or some unspecified regularity, the performance of the activity does not occur, occurs less frequently than required, or occurs less frequently than appropriate if regularity unspecified.

Information not communicated understandably

When a standard element requires that information be shared with certain persons, the information is either not shared or not shared in a manner that allows for comprehension by the recipient.

Involvement by appropriate person(s) inadequate

When a standard element requires the involvement of certain persons, those persons are either not involved or not involved in a sufficient manner.

Noncompliance with law, regulation, or other rule

When a standard element requires compliance with a legal requirement or a process for achieving legal compliance, sufficient evidence of compliance or the compliance process is not demonstrated.

Policy/plan/procedure/practice not consistently implemented

When a standard element requires a policy/plan/procedure/practice, it exists but the actual performance does not occur with sufficient regularity to be deemed standard operating procedure.

Policy/plan/procedure/practice not developed

When a standard element requires a policy/plan/procedure/practice, it is not in existence.

Policy/plan/procedure/practice not implemented

When a standard element requires a policy/plan/procedure/practice, it exists but there is no actual performance.

Policy/plan/procedure/practice recently implemented

When a standard element requires a policy/plan/procedure/practice, it exists but the actual performance has not been in place for sufficient time to establish a track record.

Training inadequate When a standard element requires that certain training occur, it either does not occur or does not occur with sufficient regularity to be deemed standard operating procedure.

Evidence of conformance inadequate When the requirement of a standard element is not satisfied, or is inconsistently satisfied and no other reasons apply.


Standard Number Standard Text

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1.C.2.a.(2) A written strategic plan: Is developed with input from: Personnel.

X

1.C.2.a.(3) A written strategic plan: Is developed with input from: Other stakeholders.

X

1.L.1.a.(1) The organization's leadership: Assesses the accessibility needs of the: Persons served. X

1.L.1.b.(9)(a) The organization's leadership: Implements an ongoing process for identification of barriers in the following areas: Any other barrier identified by the: Persons served.

X

1.L.1.b.(9)(b) The organization's leadership: Implements an ongoing process for identification of barriers in the following areas: Any other barrier identified by the: Personnel.

X

1.L.1.b.(9)(c) The organization's leadership: Implements an ongoing process for identification of barriers in the following areas: Any other barrier identified by the: Other stakeholders.

X

1.L.3.a. An accessibility status report: Is prepared annually.

X

1.L.3.c.(1) An accessibility status report: Includes: Progress made in the removal of identified barriers.

X

1.L.3.c.(2) An accessibility status report: Includes: Areas needing improvement.

X

5.D.4.a.(1) Unannounced tests of all emergency procedures: Are conducted at least annually: On each shift.

X X

5.D.4.a.(2) Unannounced tests of all emergency procedures: Are conducted at least annually: At each location.

X X

5.D.4.b. Unannounced tests of all emergency procedures: Include complete actual or simulated physical evacuation drills.

X

5.D.4.c. Unannounced tests of all emergency procedures: Are analyzed for performance improvement.

X

5.D.4.d. Unannounced tests of all emergency procedures: Result in improvement of or affirm satisfactory current practice.

X

5.D.4.e. Unannounced tests of all emergency procedures: Are evidenced in writing.

X

5.D.7.a. A written analysis of all critical incidents is provided to or conducted by the leadership: At least annually.

X

5.D.7.b.(1) A written analysis of all critical incidents is provided to or conducted by the leadership: That addresses: Causes.

X

Reasons for Partial or Non-conformance

Standards from the 2011 Business and Services Management Standards Manual were also applied during this survey. The following reflects the application of those standards.


Standard Number Standard Text

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Reasons for Partial or Non-conformance

5.D.7.b.(2) A written analysis of all critical incidents is provided to or conducted by the leadership: That addresses: Trends.

X

5.D.7.b.(3) A written analysis of all critical incidents is provided to or conducted by the leadership: That addresses: Actions for improvement. X

5.D.7.b.(4) A written analysis of all critical incidents is provided to or conducted by the leadership: That addresses: Results of performance improvement plans.

X

5.D.7.b.(5) A written analysis of all critical incidents is provided to or conducted by the leadership: That addresses: Necessary education and training of personnel.

X

5.D.7.b.(6) A written analysis of all critical incidents is provided to or conducted by the leadership: That addresses: Prevention of recurrence. X

5.D.7.b.(7) A written analysis of all critical incidents is provided to or conducted by the leadership: That addresses: Internal reporting requirements.

X

5.D.7.b.(8) A written analysis of all critical incidents is provided to or conducted by the leadership: That addresses: External reporting requirements.

X


Benchmarking This section of the Accreditation Report benchmarks your organization’s conformance to standards. By comparing strengths and areas for improvement with various comparator groups, benchmarking encourages your organization to improve effectiveness, efficiency, satisfaction, and access. This information should also stimulate discussions among stakeholders focused on better meeting the needs and preferences of the persons served. In addition, benchmarking:

♦ Encourages a culture of continuous evaluation and improvement. ♦ Accelerates understanding of and agreement on areas for improvement. ♦ Helps prioritize improvement opportunities. ♦ Shifts internal thinking toward a focus on outcomes. ♦ Provides a reference to increase performance expectations. ♦ Motivates your team to work collaboratively to surpass benchmarks.

This report provides benchmarks (mean % of conformance) for each section of the ASPIRE to Excellence® quality framework.* When available, benchmark comparison groups include:

♦ All surveyed organizations. ♦ All surveyed organizations in the same primary CARF customer service unit. ♦ Surveyed organizations with the same ownership type. ♦ Surveyed organizations in the same geographic region. ♦ Surveyed organizations with similar number of persons served annually. ♦ Surveyed organizations with similar staff size.

In addition, standards conformance for each organization undergoing resurvey is benchmarked against its previous survey in all standards areas.

Benchmark Comparison Groups

Primary area of accreditation: Aging Services (AS)

Ownership type: Other

Geographic region: Canada - ON

Staff size (FTEs): 100–499

Persons served annually: 5,000+

To receive the information contained in this section in an alternate format, please contact [email protected].

* Excluding Governance and Strategic Integrated Planning.


All surveyed organizations

75.7%

90.6%

98.6%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation

CARF One-Year Accreditation

CARF Three-Year Accreditation

ESC CCAC

% of Conformance

Lead

ersh

ip

A: Assess the Environment

50.2%

83.6%

99.6%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



ESC CCAC

% of Conformance

Inpu

t fro

m S

take

hold

ers

P: Persons Served and Other Stakeholders - Obtain Input


All surveyed organizations – continued

83.6%

92.3%

99.3%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



ESC CCAC

% of Conformance

Lega

l Req

uire

men

tsI: Implement the Plan

72.3%

91.0%

99.1%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



ESC CCAC

% of ConformanceFina

ncia

l Pla

nnin

g an

d M

anag

emen

t

I: Implement the Plan



59.4%

79.5%

97.1%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



ESC CCAC

% of Conformance

Risk

Man

agem

ent


70.0%

85.0%

96.5%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



ESC CCAC

% of Conformance

Hea

lth

and

Safe

ty




78.9%

90.0%

97.4%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



ESC CCAC

% of Conformance

Hum

an R

esou

rces


53.1%

78.3%

98.4%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



ESC CCAC

% of Conformance

Tech

nolo

gy




86.6%

93.0%

98.2%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



ESC CCAC

% of Conformance

Righ

ts o

f Per

sons

Ser

ved


46.0%

68.2%

95.3%

83.3%

0% 20% 40% 60% 80% 100%

Nonaccreditation



ESC CCAC

% of Conformance

Acc

essi

bilit

y




35.5%

62.7%

96.9%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



ESC CCAC

% of Conformance

Info

rmat

ion

Man

agem

ent a

nd

Mea

sure

men

tR: Review Results

18.0%

44.9%

94.2%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



ESC CCAC

% of Conformance

Perf

orm

ance

Impr

ovem

ent

E: Effect Change


Other benchmarks

98.8%

98.7%

98.1%

97.0%

97.7%

100.0%

0% 20% 40% 60% 80% 100%

5,000+ Persons Served

100 to 499 FTEs

Ontario

OtherOwnership Type

Aging Services

ESC CCAC

% of Conformance

Lead

ersh

ipA: Assess the Environment

100.0%

99.8%

97.9%

95.5%

99.0%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario

OtherOwnership Type

Aging Services

ESC CCAC

% of Conformance

Inpu

t fro

m S

take

hold

ers

P: Persons Served and Other Stakeholders - Obtain Input


Other benchmarks – continued

99.5%

99.3%

98.6%

97.8%

97.7%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario

OtherOwnership Type

Aging Services

ESC CCAC

% of Conformance

Lega

l Req

uire

men

ts


99.7%

99.3%

97.9%

98.5%

98.1%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario

OtherOwnership Type

Aging Services

ESC CCAC

% of ConformanceFina

ncia

l Pla

nnin

g an

d M

anag

emen

t




96.6%

97.2%

96.2%

92.3%

95.7%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario

OtherOwnership Type

Aging Services

ESC CCAC

% of Conformance

Risk

Man

agem

ent


95.4%

96.8%

90.1%

94.1%

97.0%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario

OtherOwnership Type

Aging Services

ESC CCAC

% of Conformance

Hea

lth

and

Safe

ty




97.0%

97.8%

95.0%

95.6%

95.6%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario

OtherOwnership Type

Aging Services

ESC CCAC

% of Conformance

Hum

an R

esou

rces


98.9%

98.6%

94.8%

95.5%

94.2%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario

OtherOwnership Type

Aging Services

ESC CCAC

% of Conformance

Tech

nolo

gy




97.8%

97.9%

96.5%

97.7%

97.4%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario

OtherOwnership Type

Aging Services

ESC CCAC

% of Conformance

Righ

ts o

f Per

sons

Ser

ved


95.0%

95.4%

91.2%

92.5%

91.6%

83.3%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario

OtherOwnership Type

Aging Services

ESC CCAC

% of Conformance

Acc

essi

bilit

y




97.6%

97.7%

96.5%

92.2%

97.2%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario

OtherOwnership Type

Aging Services

ESC CCAC

% of Conformance

Info

rmat

ion

Mea

sure

men

t an

d M

anag

emen

t

R: Review Results

95.6%

95.9%

94.0%

86.4%

96.1%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario

OtherOwnership Type

Aging Services

ESC CCAC

% of Conformance

Perf

orm

ance

Impr

ovem

ent

E: Effect Change


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