Transcript Overview of the On-Site Survey

On-site Survey Debriefing
CASA Child, Adolescent and Family
Mental Health
21/10/2013 - 24/10/2013
The 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
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21/10/2013 - 24/10/2013
Genevieve Corbin
Doreen Fey
Kevin Hayes
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Preliminary 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 Strengths
 Innovation ie new Front Door Services
 Effective Outreach
 Generosity of Spirit
 Organizations Report Card and Targets
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Overall 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 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 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 …
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Patient safety
Ethics
Risk management
Quality improvement
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Patient safety
 Strengths
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Client and family education
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Hand Hygiene Audits
 Areas for improvement
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Report on progress to staff, leaders and Board
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Ethics
 Strengths
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Staff survey to understand the importance of ethics
process
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Research ethics framework has been developed
 Areas for improvement:
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Complete the action plan
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Develop framework
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Risk management
 Strengths
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Job hazard analysis
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Health and safety audit
 Areas for improvement
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Complete the risk assessment process
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Develop risk framework and risk mitigation plan
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CASA Center
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Quality improvement
 Strengths
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Focus on consultation during improvement
activities
Evaluation at a glance
 Areas for improvement
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Integrate the framework

Prioritize improvement projects
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Reaching 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 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 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 us
Accreditation Canada
1150 Cyrville Road
Ottawa, ON Canada K1J 7S9
Tel: 1-800-814-7769 or 613-738-3800
Fax: 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.
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