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ACCREDI TATIONEVERYONE. REA DY. EVERY DAY.LHSCOur continuing quality and safety journeyLHSC Accreditation 2023Sanitize hands before you flip

2LHSC ACCREDITATION 2023Our continuing quality and safety journeyTable of contentsPeople-Centered Care14Safety Culture16Communication22Medication Use34Worklife/Workforce46Infection Control56Risk Assessment62This flip book provides high level information on all you need to know for our Accreditation Onsite Survey February 12-16, 2023. This is a quick reference tool for our staff, physicians, students and volunteers.

3LHSC ACCREDITATION 2023Our continuing quality and safety journeyWhat is Accreditation?Accreditation is a method by which LHSC processes are assessed against global standards as a means of continually improving quality of care. LHSC Mission, Vision and Values and Accreditation• Using our values of compassion, teamwork, curiosity, and accountability to achieve our vision working together to shape the future of health.• Our mission at LHSC is a leading academic health organization committed to collaborating with patients, families and system partners to: o Deliver excellent care experiences and outcomes; o Educate the health-care providers of tomorrow; and o Advance new discoveries and innovations that optimize the health and wellbeing of those we serve.• These guide the work we do every day which is measured by Accreditation. This is our road to exemplary!

4LHSC ACCREDITATION 2023Our continuing quality and safety journeyWhat will happen?• Accreditation Canada surveyors conduct surveys throughout LHSC and Children’s Hospital, including off-site locations.• Surveyors meet with staff, physicians and even patients, engaging them and asking questions.• These quick Q&A sessions focus on what you do every day.Questions? Ask your Leader, Hospital Champion or visit the Accreditation intranet page.

5LHSC ACCREDITATION 2023Our continuing quality and safety journey8 Tips to help you with AccreditationNote for Accreditation: Accreditation Canada uses the term ‘Client’ where LHSC uses the term ‘Patient’.Be clear and concise. Start broad and become more specific in your answers.If you don’t know the answer, show where you would access information.Provide examples of compliance.Take a breath and introduce yourself.Show how you include patients and caregivers. If you are unsure what the surveyor is asking, ask them to rephrase their question. It’s okay to say ‘I’m busy giving patient care’ can I come back to you?Don’t forget to brag and have fun!

6LHSC ACCREDITATION 2023Our continuing quality and safety journeyPatient Safety PlanLondon Health Sciences Centre’s 2022-2026 Patient Safety Plan (available on the LHSC Patient Safety intranet) is a guiding document that represents a new direction and significant shift in patient safety culture.Through the implementation of a proactive and resilient system of patient safety management, this plan will drive forward the LHSC strategic direction to deliver exceptional equality and safety.Everyone has a role to play. In this plan, risks are anticipated and managed in advance and incidents are reviewed from a learning perspective.This plan has a quick reference one-pager that can be printed off and placed on huddle boards.

7LHSC ACCREDITATION 2023Our continuing quality and safety journeyNEW for 2022! People-Centred Care Priority ProcessThis new priority process from Accreditation Canada requires all members of team LHSC to:• Be responsible for adopting a people-centred care approach, and• Take action to ensure patients and care partners are active participants in their care.The Patient Experience program has created a Patient Experience Resource Guide (available on the Accreditation intranet page) as a resource for all staff, physicians and leaders on including the patient and care partner perspective into daily practice using people-centred care approaches.Every unit, program and department throughout our entire hospital is evaluated by Accreditation Canada on our people-centred care approach; from the bedside to the boardroom.

LHSC ACCREDITATION 2023Our continuing quality and safety journey8What you need to know about ROPsAccreditation Onsite Survey - February 12-16, 2023 Shine and Be Proud! 8

LHSC ACCREDITATION 2023Our continuing quality and safety journey9ROPs for Nursing The following is a list of key ROPs for nursing:Information Transfer at Care Transitions 26Hand Hygiene Compliance/ Education and Training56 58Medication Reconciliation2830Falls Prevention and Injury Reduction 62High-Alert Medications 36 Pressure Ulcer Prevention 64Infusion Pump Safety 42 VTE Prophylaxis 68Preventative Maintenance Program 52 Suicide Prevention 66Workplace Violence Prevention 54Want more information? Ask your Leader, Hospital Champion, or reach out to Accreditation.Team@lhsc.on.ca.

LHSC ACCREDITATION 2023Our continuing quality and safety journey10Want more information? Ask your Leader, Hospital Champion, or reach out to Accreditation.Team@lhsc.on.ca. ROPs for Physicians The following is a list of key ROPs for physicians:Patient Safety Incident Disclosure and Management18 High-Alert Medications 36Information Transfer at Care Transitions26 Workplace Violence Prevention 54Medication Reconciliation2830Hand Hygiene Compliance/ Education and Training5658

LHSC ACCREDITATION 2023Our continuing quality and safety journey11Want more information? Ask your Leader, Hospital Champion, or reach out to Accreditation.Team@lhsc.on.ca. ROPs for Professional Health Disciplines The following is a list of key ROPs for Health Disciplines:Information Transfer at Care Transitions 26 Falls Prevention and Injury Reduction 62Medication Reconciliation2830Pressure Ulcer Prevention 64Workplace Violence Prevention 54 VTE Prophylaxis 68Hand Hygiene Compliance/Education and Training5658Suicide Prevention 66

LHSC ACCREDITATION 2023Our continuing quality and safety journey12* Appropriate Cleaning and Disinfection of Environment and Equipment as per IPAC Best Practices.ROPs for Environmental Services/ Porters/PSWs/Ambulatory Clerks The following is a list of key ROPs for Environmental Services, Porters, PSWs and Ambulatory Clerks: Client Identification 22Hand Hygiene Compliance/ Education and Training 5658Information Transfer at Care Transitions26 Falls Prevention and Injury Reduction 62Want more information? Ask your Leader, Hospital Champion, or reach out to Accreditation.Team@lhsc.on.ca.

13LHSC ACCREDITATION 2023Our continuing quality and safety journeyWhat else do you need to know?• Ensure you understand our Privacy & Confidentiality policy • Know how to enter an AEMS • Know that LHSC has an Ethics Framework and more information is available on the Ethics Intranet Site • Understand Consent for Treatment • Informed consent • Consent and Capacity board • Be able to articulate that to register a complaint for a patient and/or family you would contact Patient Relations at x58230 or by e-mail at patientrelations@lhsc.on.ca • Make sure you know what to do when there’s been a potential Privacy breach • Health care associated infections are tracked, analyzed and are reported to the organization and publicly reported Use the QR Code on the back of this booklet to visit the Accreditation intranet for links to documents referenced.Want more information? Ask your Leader, Hospital Champion, or reach out to Accreditation.Team@lhsc.on.ca.

PEOPLE-CENTERED CARELHSC ACCREDITATION 2023Our continuing quality and safety journey14Questions1. How do you ensure each patient has a voice in the planning and delivery of care? 2. What are some activities that Patient Partners have been a part of? 3. Does LHSC have a strategic plan related to People-Centred Care?Working with clients and their families to plan, improve and provide care that is respectful, compassionate, culturally safe, and competent.

PEOPLE-CENTERED CARE15 Answers:1. Honour patient perspectives and choices, encourage patients to take part in decision-making, and leverage our core values of compassion, teamwork, curiosity and accountability. 2. We have collaborated with patient partners on many initiatives, including COVID-19 family presence policies and on strategic planning. 3. Yes. LHSC’s Patient Experience Strategic Plan describes our vision for people-centred care and how we engage patients and families in their care.Did you know?There are 71 Patient and Family Partners at LHSC and Children’s Hospital. Since April 2021, there have been 80 requests to engage with them. People-centred care includes everyone who is a part of the effort to deliver high-quality care: patients, family members, staff, physicians and volunteers. We use the Engagement Framework from Health Quality Ontario to structure our partnerships. Our Patient and Family Advisory Councils help review, advise, and co-design hospital initiatives. A total of 46 Patient and Family Partners take part in these councils.

LHSC ACCREDITATION 2023Our continuing quality and safety journeySAFETY CULTURE16Questions1. How does the Board of Directors stay informed about quality? 2. How does the Board hear about patient experiences? 3. How does the Board support a culture of patient safety? Accountability for qualityThe Board of Directors demonstrates accountability for the quality of care provided by the organization.

SAFETY CULTURE17 Answers:1. Each month, the Board receives information on key performance measures, such as patient experiences, patient safety, and staff/physician safety. 2. Board meetings include discussion of patient stories that highlight aspects of our quality journey. The Board’s Quality Committee includes two Patient Partners as voting members. 3. The Board sets annual strategic priorities, including priorities for patient safety.Did you know?Our Board is a group of volunteers across the community who hold our executive team accountable to the province, community and staff. Members are selected based on their skills and experiences. We have a strong desire to have our Board closely reflect the diverse populations served by the hospital. The Board ensures the organization sets strategic priorities to enable safe, high-quality care and uses our ethics framework to help set these priorities.

LHSC ACCREDITATION 2023Our continuing quality and safety journeySAFETY CULTURE18Questions1. How would you disclose a safety incident to a patient? 2. Are resources available to support staff during disclosures? 3. Is there a process for patients and families to voice their concerns? Patient safety incident disclosure and management A documented and coordinated approach to disclosing patient safety incidents to clients and families, that promotes communication and a supportive response, is implemented.

SAFETY CULTURE19 Answers:1. By informing the patient of what happened (using the information you currently know), offering an apology, and discussing immediate actions that will be taken to reduce further harm. 2. Leaders and Patient Relations work together to support staff during disclosures. Resources are also available on the LHSC intranet under Resources > Patient Safety. 3. Yes. The Patient Relations department is accessible by phone or email. We provide this information to patients and families when they are admitted.Did you know? Our disclosure process was co-designed with our Patient Experience Advisory Committee to ensure a thoughtful and compassionate experience for families. When staff members come forward and acknowledge responsibility (for example, by apologizing), the overall trauma associated with the incident can be greatly reduced for patients. In high-income countries, it is estimated that one in every 10 patients is harmed while receiving hospital care. A range of adverse events can cause harm, with nearly 50% being preventable.

LHSC ACCREDITATION 2023Our continuing quality and safety journeySAFETY CULTURE20Questions1. Are quarterly reports regarding patient safety trends sent to our Board of Directors? 2. How is the Board kept informed of advancements regarding LHSC’s Patient Safety Plan? 3. How does the Board help support patient safety at the organization? Patient safety quarterly reportsThe Board of Directors are provided with quarterly reports on patient safety that include recommended actions arising out of patient safety incident analysis, as well as improvements that were made.

SAFETY CULTURE21 Answers:1. Yes, the Board of Directors receives reports on publicly reported patient safety indicators that speak to trends (e.g. Hand Hygiene, Surgical Safety Checklist), along with the interventions put in place to improve these metrics. 2. The Board receives quarterly updates on the progress of LHSC’s Patient Safety Plan and interventions that have been implemented. 3. The Board helps support patient safety activities by dedicating at least 25% of agenda items to patient safety, ensuring follow-up occurs on all critical incidents, and by acting on the recommendations it receives.Did you know?Last year alone there were 7,503 patient safety incidents with 41 of the more severe Level 4 incidents and two Level 5 incidents. Our top patient safety incidents were:• Falls• Medication Related• Treatment/Procedure RelatedThe Medical Advisory Committee, Quality and Culture Sub-committee of the LHSC Board and the Quality and Patient Safety Council all receive regular updates on patient safety incidents.

COMMUNICATIONLHSC ACCREDITATION 2023Our continuing quality and safety journey22Questions1. How do you verify the identity of a patient? 2. What are examples of patient identifiers? 3. In what situations is the use of two patient identifiers necessary? Client IdentificationWorking in partnership with clients and families, at least two person-specific identifiers are used to confirm that clients receive the service or procedure intended for them.

COMMUNICATION23 Answers:1. At least two patient-specific identifiers are used to confirm that patients receive the service or procedure that is intended for them. Facial recognition is not an allowable identifier unless a picture is on file. 2. Examples include the patient’s full name, date of birth, Patient Identification Number, home address, or Health Card. • Prior to providing services or interventions • At the time of patient registration, scheduling, and appointment check-in • At the start of each shift, or during each clinician’s initial interaction with the patientDid you know?Our audits show an overall compliance rate of 91% for patient scanning. Patient misidentification is a medical error. Avoiding these errors requires systemic preventive strategies. Many patient identification errors affect at least two people. For example, the patient who received the wrong medication and the patient whose medication was omitted can both suffer harm.

COMMUNICATIONLHSC ACCREDITATION 2023Our continuing quality and safety journey24Questions1. Why do we have a Do Not Use List of Abbreviations? 2. If you wanted to know if an abbreviation is on the Do Not Use List, where would you look? 3. How are staff informed of recent additions to the list? The “Do Not Use” List of AbbreviationsA list of abbreviations, symbols, and dose designations that are not to be used has been identified and implemented.

COMMUNICATION25 Answers:1. The List helps prevent errors by avoiding the use of ambiguous symbols and abbreviations. 2. The List is posted in medication rooms and is available on the LHSC intranet under Programs and Services. 3. Staff are informed through the clinical educators, during in-person training sessions, and through unit emails.Did you know?Approximately 5% of medication errors are attributed to abbreviations. Unclear abbreviations can cause serious patient safety events. For instance, the Institute for Safe Medication Practices notes how the letter “u”, when used to abbreviate “units”, can be interpreted as a zero and cause a 10-fold increase in the medication administered. Medication PowerPlans are reviewed for compliance with the “Do Not Use” List.

COMMUNICATIONLHSC ACCREDITATION 2023Our continuing quality and safety journey26Questions1. What does SBAR stand for? 2. When should transfer of information be completed? 3. How can you involve patients and families in information transfer? Information Transfer at Care TransitionsInformation relevant to the care of the patient is communicated effectively during care transitions.

COMMUNICATION27 Answers:1. SBAR is a standardized communication tool that stands for Situation, Background, Assessment, Recommendation. 2. During admission, shift-to-shift handover, select in-hospital transfers, inter-facility transfers, and at discharge. 3. You can give report at the bedside, ask if the family members have questions, update the bedside whiteboard, and ensure the family knows the up-to-date plan of care.Did you know? 60-70% of all adverse events have some element of communication failure. Using SBAR during bedside report increases patient and family satisfaction and also increases their level of comfort when dealing with challenging situations.

COMMUNICATIONLHSC ACCREDITATION 2023Our continuing quality and safety journey28Questions1. How are staff educated on the Med Rec process? 2. How are Med Rec compliance rates shared with staff? 3. Who is responsible for completing the Med Rec? Medication Reconciliation (Med Rec) as a strategic priorityA documented and coordinated medication reconciliation process is used to communicate complete and accurate information about medications across care transitions.

COMMUNICATION29 Answers:1. Education is provided to staff during orientation and through unit in-services. Resources are also available on the LHSC intranet. 2. LHSC reports metrics through the reporting hub and through physician indicator reports. 3. The physician, pharmacist or Nurse Practitioner completes the Med Rec.Did you know? Medication Reconciliation is recognized as a key safety initiative by the World Health Organization. LHSC has a dedicated committee called the Medication Reconciliation Optimization Committee. LHSC audits Med Recs across admissions, discharges and in ambulatory clinics.

COMMUNICATIONLHSC ACCREDITATION 2023Our continuing quality and safety journey30Questions1. When does Med Rec need to be completed? 2. What is the purpose of Med Rec? 3. What does BPMH stand for? Who is responsible for completing it? Medication Reconciliation (Med Rec) at care transitionsMedication Reconciliation is conducted in partnership with clients and families to communicate accurate and complete information about medications across care transitions.

COMMUNICATION31 Answers:1. Med Rec must be completed on admission, during transfer of care, and at the time of discharge. 2. Med Rec compares and resolves discrepancies between the BPMH and the Medication Orders to ensure appropriate medication are ordered and to avoid unintended omissions or continuations. 3. BPMH stands for Best Possible Medication History. The first member of the healthcare team in contact with the patient documents the BPMH.Did you know? At LHSC, the average time to complete a Med Rec for non-complex patients is 30-60 seconds. Even if a patient is waiting within the ED for an inpatient bed, the BPMH must be completed as soon as the decision to admit is made. At LHSC, approximately 85% of BPMHs are completed within 24 hours of admission.

COMMUNICATIONLHSC ACCREDITATION 2023Our continuing quality and safety journey32Questions1. Why do we use the safe surgery checklist at LHSC? 2. What are the three key phases of a surgical procedure when the safe surgery checklist is used? 3. When is the safe surgery checklist used? Safe surgery checklistA safe surgery checklist is used to confirm that safety steps are completed for a surgical procedure performed in the operating room.

COMMUNICATION33 Answers:1. The safe surgery checklist is a communication tool to help the surgical team confirm important details of a patient’s case. 2. The three key phases are: (1) The briefing phase, which is before the patient receives anaesthesia; (2) The time out phase, which is before the procedure begins; and (3) The debriefing phase, which is before the procedure ends. 3. The safe surgery checklist is used for every surgery at LHSC.Did you know? Our compliance rates are posted on the external website every six months. For the last two years, LHSC has achieved a compliance rate of over 99%. According to the WHO, since the safe surgery checklist came into effect in 2008, mortality and complication rates have been reduced worldwide by over 30%. Standardized tools and processes help improve safety.

MEDICATION USELHSC ACCREDITATION 2023Our continuing quality and safety journey34Questions1. What is the purpose of LHSC’s Antimicrobial Stewardship Program? 2. How are antibiotics prescribed for patients? 3. How are patients and families educated on antimicrobial use and the risks of antimicrobial resistance? Antimicrobial Stewardship There is an Antimicrobial Stewardship Program to optimize antimicrobial use.

MEDICATION USE35 Answers:1. The program’s function is to ensure the appropriate use of antimicrobials to achieve the best possible patient outcomes with the lowest risk for subsequent antibiotic resistance. 2. Guides are available on the LHSC intranet that detail which antibiotics to prescribe and when. These are located on the Antimicrobial Stewardship page under Clinical Pathways and Guidelines. 3. Education happens through “in the moment” teaching and via patient education brochures.Did you know? Hand hygiene and proper PPE use can help reduce the spread of antimicrobial resistant organisms. The WHO lists “superbugs” as one of the top 10 public health threats facing humanity.

MEDICATION USELHSC ACCREDITATION 2023Our continuing quality and safety journey36Questions1. When is an independent double check needed and how is it completed? 2. Can you name three high alert medications? 3. Where can you find monitoring requirements for medications? High-alert medications A documented and coordinated approach to safely manage high- alert medications is implemented.

MEDICATION USE37 Answers:1. An independent double check is required before administering a high alert medication. A second nurse or RHP verifies the patient, medication order, infusion pump program (if applicable), and prepared medication prior to administration. 2. Examples include Opioids, Heparin and Insulin. 3. Monitoring requirements can be found in the Parenteral Drug Administration Manual (PDAM), located under Manuals and Guides on the LHSC intranet.Did you know? The most common high-alert medications used at LHSC are opioids, hypoglycemics, and anticoagulants. The PINCH acronym is a good way to remember which medications are “high-alert”: P: Potassium, and other electrolytes I: Insulin N: Narcotics (opioids), and sedatives C: Chemotherapy drugs H: Heparin

MEDICATION USELHSC ACCREDITATION 2023Our continuing quality and safety journey38Questions1. What safety precautions should you take before administering IV heparin? 2. Who oversees all high-alert medications, including heparin infusions? 3. How are patients educated about heparin?Heparin safetyThe availability of heparin products is evaluated and limited to ensure that formats with potential to cause patient safety incidents are not stocked in patient service areas.

MEDICATION USE39 Answers:1. IV Heparin is a high-alert medication. An independent double check is performed before administering. 2. Pharmacy oversees all safeguards for high-alert medications. 3. Patient teaching occurs before administration and includes the purpose and risks of the medication.Did you know? Heparin is the oldest anticoagulant used in clinical medicine. The American Jay McLean discovered heparin in 1916 as a second-year medical student at Johns Hopkins University.

MEDICATION USELHSC ACCREDITATION 2023Our continuing quality and safety journey40Questions1. How are concentrated electrolytes stored and dispensed? 2. What is one example of a concentrated electrolyte kept in patient areas? 3. Where can you find information about the safe administration of concentrated electrolytes? Concentrated electrolytesThe availability of concentrated electrolytes is evaluated and limited to ensure that formats with the potential to cause patient safety incidents are not stocked in client service areas.

MEDICATION USE41 Answers:1. Concentrated electrolytes are stored and dispensed by Pharmacy. Storage areas need to be approved by Pharmacy. 2. An example would be calcium chloride pre-filled syringes, which are stored on all crash carts. 3. You can find this information in the PDAM, located under the Manuals and Guide tab on the LHSC intranet.Did you know? High-alert medications may cause serious harm if administered in error. The Institute for Safe Medication Practices has highlighted independent double check failures and insufficient patient engagement as common themes in critical incidents involving high-alert medications.

MEDICATION USELHSC ACCREDITATION 2023Our continuing quality and safety journey42Questions1. How are staff trained to use infusion pumps? 2. How do infusion pumps help ensure safe delivery of medication? 3. What would you do if you needed to operate an unfamiliar infusion pump? Infusion pump safetyA documented and coordinated approach for infusion pump safety that includes training, evaluation of competence, and a process to report problems with infusion pump use is implemented.

MEDICATION USE43 Answers:1. Clinical staff receive training during orientation. When infusion pumps are used infrequently, “just in time” training occurs. 2. Pumps are programmed with dose limits and drug profiles to prevent medication errors. 3. Speak with the unit educator and other trained staff. Review infusion pump resources on the LHSC intranet under Manuals and Guides.Did you know? Infusion pumps are a tool to enhance infusion safety, but the device does not replace clinical assessment and judgement. 3,102 nurses are trained bi-annually at LHSC. The first infusion pump was invented by the British architect, Christopher Wren, way back in 1658.

MEDICATION USELHSC ACCREDITATION 2023Our continuing quality and safety journey44Questions1. When is training provided on narcotic medications? 2. What safety precautions are taken prior to administering narcotic medications? 3. Where should you keep narcotic keys? Narcotics safetyThe availability of narcotic products is evaluated and limited to ensure that formats with the potential to cause patient safety incidents are not stocked in client service areas.

MEDICATION USE45 Answers:1. Nurses receive training during central nursing orientation. Clinical staff follow Pharmacy policies related to safe narcotic storage on their units.2. Verifying the rights of medication administration, using a programmable IV pump (if applicable), and completing an independent double check for high-alert medications. 3. Keys must always be with an authorized person. They should be on the unit at all times and locked in a secured environment when not in use.Did you know? Withdrawal symptoms start eight hours after the last use and can last up to 30 days. Over the past decade, LHSC has undertaken several quality initiatives to help reduce opioid prescription as part of Cut the Count provincial initiative.

WORKLIFE / WORKFORCELHSC ACCREDITATION 2023Our continuing quality and safety journey46Questions1. What information is used to manage client flow? 2. Can you explain how LHSC manages a “Code Gridlock”? 3. Can you describe the process for preparing the patient for safe and timely discharge? Client flowClient flow is improved throughout the organization and emergency department overcrowding is mitigated by working proactively with internal teams and teams from other sectors.

WORKLIFE / WORKFORCE47 Answers:1. Daily metrics reports are provided to monitor client flow across the organization, including the number of ED admissions and patient discharges. This is coordinated through Patient Access and Flow. 2. On inpatient units, staff identify and prepare patients for imminent discharge and pull admitted patients from the ED as soon as possible. 3. As far ahead as possible, staff ensure patients and care partners are aware of the discharge time, transportation needs are confirmed, and plans are made for required follow-up.Did you know? Last year, LHSC had 42,925 admissions, 738,396 ambulatory visits, 166,798 emergency visits, and completed 24,994 surgeries. Last year, we had two Code Gridlocks across all sites. As soon as the anticipated date of discharge is known, it should be communicated to the patient and written on the bedside whiteboard.

WORKLIFE / WORKFORCELHSC ACCREDITATION 2023Our continuing quality and safety journey48Patient safety: education and training Patient safety training and education that addresses specific patient safety focus areas are provided at least annually to leaders, team members, and volunteers. Questions1. What types of educational opportunities are you provided for patient safety? 2. How do you make sure your patients are safe? 3. How do you educate patients about safety as it relates to their care?

WORKLIFE / WORKFORCE49 Answers:1. Regular education is provided by unit educators and via online iLearn modules. 2. Practices include proper hand hygiene, keeping patient rooms free of clutter, ensuring the patient’s bed is at the lowest level, and the use of various assessment tools, such as the Braden Scale, Falls Risk assessment and Suicide Risk assessment. 3. Patients are provided one-on-one education on topics such as risks associated with medications, falls, and care at home.Did you know? Receiving care in the hospital is not without risk. The WHO estimates one in 10 patients may experience a preventable harm event. To reduce healthcare risk, we must: • Ensure a fair and just safety culture; • Look to system and process improvements, rather than individuals; • Encourage all hospital staff to work as one team.

WORKLIFE / WORKFORCELHSC ACCREDITATION 2023Our continuing quality and safety journey50Patient safety planA patient safety plan is developed and implemented for the organization. Questions1. How are safety concerns identified and addressed? 2. Is there a patient safety plan for the organization? 3. How are team-level priorities for safety and quality improvement identified?

WORKLIFE / WORKFORCE51 Answers:1. AEMS data helps identify patient safety concerns, along with various patient care metrics and concerns raised by staff and patients. 2. Yes, LHSC has a new 2022-2026 Patient Safety Plan in place. It includes initiatives to improve patient safety and can be found on the LHSC Patient Safety intranet page. 3. Through avenues such as AEMS reports and safety huddles, LHSC encourages all staff, leaders, and physicians to offer their ideas for quality improvement. Did you know? Patient Safety Champion Awards celebrate excellence at LHSC. This year there were 37 outstanding nominations. A Patient Safety Plan one-page overview is available on the intranet and can be printed and displayed on huddle boards.

WORKLIFE / WORKFORCELHSC ACCREDITATION 2023Our continuing quality and safety journey52Preventative Maintenance program Patient safety training and education A preventative maintenance program for medical devices, medical equipment, and medical technology is implemented. Questions1. Is there a preventative maintenance (PM) program for medical devices and equipment? 2. How can you verify that a piece of equipment has received its regular maintenance? 3. What is the process for reporting equipment that is not working?

WORKLIFE / WORKFORCE53 Answers:1. Yes, LHSC has a PM program in place for all medical devices and equipment. 2. Stickers show the required PM dates. BioMed is responsible for medical equipment, which has a green PM sticker. A red sticker means the equipment should not be used. 3. Remove the equipment from use, notify BioMed or Facilities Maintenance, and complete an AEMS if there is a safety hazard.Did you know? Responsibility for the PM program is shared between BioMed and Facilities Management. If you are unsure who to contact, ask your leader. BioMed tests all hospital equipment, including new purchases, before they are put into service.

WORKLIFE / WORKFORCELHSC ACCREDITATION 2023Our continuing quality and safety journey54Workplace violence preventionA documented and coordinated approach to prevent workplace violence is implemented.Questions1. What is the process for reporting workplace violence? 2. What training is available to protect yourself and others from violence? 3. Are there policies on workplace violence?

WORKLIFE / WORKFORCE55 Answers:1. Workplace violence is reported through the AEMS system. Leaders and Human Resources staff are notified and an investigation is initiated. 2. LHSC provides workplace violence prevention training to all staff and physicians. 3. Workplace violence policies are available on the PolicyManager (LHSC) intranet page, along with workplace violence prevention tools.Did you know? Workplace violence is more common in healthcare settings than in most other workplaces. Last year there were 2,200 reported instances at LHSC. We monitor workplace violence, which is a key part of our Quality Improvement Plan, and report this metric to the board.

INFECTION CONTROLLHSC ACCREDITATION 2023Our continuing quality and safety journey56Hand hygiene complianceCompliance with accepted hand-hygiene practices is measured. Questions1. Why is proper hand hygiene important? 2. What are the four moments of hand hygiene? 3. How is hand hygiene compliance measured at LHSC?

INFECTION CONTROL57 Answers:1. Hand hygiene is considered the single most important way to reduce health care-associated infections. 2. (1) Before initial contact with the patient or their environment; (2) Before a clean/aseptic procedure; (3) After body fluid exposure risk; and (4) After touching a patient or their environment. 3. Trained auditors who observe hand hygiene practices measure our compliance. Rates are posted on units and on the Infection Control pages of the intranet.Did you know? Gloves are not a substitute for proper hand hygiene. Hand hygiene is required before and after glove use. Every year, our hand hygiene rates are reported to the Ministry of Health and Long-Term Care. On average over the last three years, LHSC’s hand hygiene compliance rate has been 97%.

INFECTION CONTROLLHSC ACCREDITATION 2023Our continuing quality and safety journey58Hand hygiene education and training Hand hygiene education is provided to team members and volunteers.Questions1. Where do you receive hand hygiene education and training? 2. When do you use soap and water versus alcohol- based hand rub? 3. How are patients and visitors educated on hand hygiene practices?

INFECTION CONTROL59 Answers:1. Infection Prevention and Control educates new hires, students and volunteers. All staff receive annual iLearn training and clinical staff receive ongoing training from clinical educators. 2. Alcohol-based hand rub is the preferred method when hands are not visibly soiled. Wash visibly soiled hands with soap and water. 3. Patients and visitors are educated via the Patient Handbook, fact sheets, unit signage and by staff members discussing and modelling proper hand hygiene practices. Did you know? 91% of patients feel more confident about the health care system knowing there is a hand hygiene program in place. Family and visitors can spread infections to patients without knowing. Since “superbugs” and other germs can live on many surfaces, it is essential that visitors follow hand hygiene guidelines.

INFECTION CONTROLLHSC ACCREDITATION 2023Our continuing quality and safety journey60Infection ratesHealth care-associated infections are tracked, information is analyzed to identify outbreaks and trends, and this information is shared throughout the organization.Questions1. Describe your role in reducing health-care associated infections in your area. 2. Where do you receive updated information on infection prevention and control? 3. How are patients, families and staff made aware of an ongoing outbreak?

INFECTION CONTROL61 Answers:1. Following all routine and additional precaution requirements (for instance, isolation rooms, PPE use), performing hand hygiene at the four moments, and staying up-to-date on information from the IPAC team. 2. The IPAC team and clinical leaders share information with staff and physicians at unit huddles, by email, and through LHSC intranet resources. 3. Patients and families will see appropriate signage on the unit. The IPAC team informs unit leaders and frontline staff via unit huddles and email. Outbreaks are posted on the external website. Did you know? LHSC has 16 full-time Infection Control Professionals that provide support across all three hospitals. IPAC analyzes every outbreak and makes recommendations to prevent recurrences. Hospital data for various infections, including C. Diff, MRSA and VRE, is available on LHSC’s external website.

RISK ASSESSMENTLHSC ACCREDITATION 2023Our continuing quality and safety journey62Questions1. Who is at risk of falling? 2. When are patients at risk of falling identified? 3. What are some examples of Required Universal Falls Precautions? 4. What factors increase a patient’s risk of falling? Falls prevention and injury reductionTo prevent falls and reduce the risk of injuries from falling, universal precautions are implemented, education and information are provided, and activities are evaluated.

RISK ASSESSMENT63 Answers:1. All hospital patients are at risk of falling. 2. Inpatients are assessed on admission, after a fall, with any change in medical condition, weekly (at minimum), and when transferred. 3. Examples include ensuring that call bells are within reach and functioning, trip hazards are removed, beds are at the appropriate height, wheelchair and stretcher brakes are on, and patients use non-slip footwear. 4. Factors include a change of environment, dehydration, a history of falls, poor footwear, balance/gait impairments, muscle weakness, cognitive impairments, medications, and lack of sleep.Did you know? LHSC’s ED sees over 12,000 patients per year because of falls. 18% of those patients are admitted because of their injuries. Falls are one of the top three incidents captured in our AEMS reporting system. Last year, there were 1,528 AEMS incidents related to falls. The Prevention of Falls and Pressure Injury Monitoring Committee monitors the numbers of falls at LHSC.

RISK ASSESSMENTLHSC ACCREDITATION 2023Our continuing quality and safety journey64Questions1. Which factors increase the risk of a patient developing a pressure injury? 2. What are the major factors that contribute to pressure injuries? 3. What are some interventions to help reduce the incidence of pressure injuries? Pressure ulcer preventionEach client’s risk for developing a pressure ulcer is assessed and interventions to prevent pressure ulcers are implemented.

RISK ASSESSMENT65 Answers:1. Poor nutrition, decreased mobility, impaired skin integrity, incontinence, decreased perfusion, and altered LOC. 2. Increased pressure to bony prominences, moisture, friction and shear, increased number of linen layers, and poor nutrition. 3. Turning and repositioning the patient as per protocol, using two or fewer layers of linen beneath the patient, and using a pressure off-loading device. Did you know? The Braden and Braden Q have patient interventions included right on the power-form. The top three locations of pressure injuries are sacrum/coccyx, heels, and buttocks. Last year, 15% of inpatients were identified as having a hospital-acquired pressure injury. These injuries are monitored by the Prevention of Falls and Pressure Injury Monitoring Committee and the Skin and Wound Care Committee.

RISK ASSESSMENTLHSC ACCREDITATION 2023Our continuing quality and safety journey66Questions1. How often is suicide screening completed? 2. What screening tool is used to identify patients at risk for suicide? 3. What are some interventions that can help ensure patient safety? Suicide preventionClients are assessed and monitored for risk of suicide.

RISK ASSESSMENT67 Answers:1. Suicide screening should be completed every 12 hours for patients who have made gestures or statements to indicate suicidal ideation or are being admitted for treatment following a suspected suicide attempt. 2. The Columbia Suicide Severity Rating Scale (CSSRS), as well as the Ask Suicide-Screening Questions (ASQ) in the Children’s ED. 3. Notify the MRP of concerns, complete regular screening assessments, implement a safety checklist, consider the need for one-on-one observation, and consult with social work, spiritual care, and/or mental health.Did you know? Every year, over 4,000 people in Canada die by suicide. The contemplation of suicide results from complex interactions of personal perception of life experiences.

RISK ASSESSMENTLHSC ACCREDITATION 2023Our continuing quality and safety journey68Questions1. How are patients at risk of VTE (venous thromboembolism) identified? 2. What would classify a patient as high risk for a VTE? 3. How are patients and families educated about VTE? Venous thromboembolism prophylaxis Medical and surgical clients at risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) are identified and provided with appropriate thromboprophylaxis.

RISK ASSESSMENT69 Answers:1. Patients are identified through a medical history, head-to-toe assessment, consideration of the type of surgery, or observed risk. 2. High-risk patients include those with mobility issues > 72 hrs., active cancer or cancer treatment, previous history of VTE or stroke, acute medical illness, and recent surgical procedures. 3. Patients and families are given an educational brochure prior to surgery. They also receive in-the-moment teaching on reducing risk while in hospital. Did you know? 33% of patients who develop a DVT or PE will have a recurrence within 10 years. The rate of hospital-acquired VTE, if prophylaxis is not used, is 10-40% after general surgery and 40-60% after hip surgery.

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