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Likely will be recognized nationwide
has having two “Leading Practices”
The Thunder Bay Regional Health Sciences Centre recently underwent
its three-year accreditation, receiving an impressive 97.2%
mark. Most exciting though is the fact that the Health Sciences
Centre will likely be recognized as having not one but two
“Leading Practices” that other institutions in
Canada will study and learn from, said Accreditation Coordinator
Gary Ferguson.
“Leading Practices are areas that we feel we do extremely
well, and would like to highlight,” Ferguson said. “For
example, we’re unique in how far we’ve carried
our Patient and Family Centred Care (PFCC) model of healthcare
in two short years.”
Telemedicine, the Health Sciences Centre videoconferencing
communications system, is the other area Ferguson expects
will be recognized as a Leading Practice.
Accreditation Canada, the nonprofit organization that conducts
the reviews, describes Leading Practices as practices “worthy
of recognition as organizations strive for excellence in their
specific field, or commendable for what they contribute to
healthcare as a whole.”
What Is Accreditation?
Accreditation itself is a review by this independent agency
to gauge how well the facility operates compared to national
standards based on many different criteria.
Accreditation is important for the Health Sciences Centre
for several reasons. For one, facilities must be accredited
in order to host academic and research activities. It also
gives the Health Sciences Centre the opportunity to review
its practices and improve where necessary.
Scores are given as a system of flags: a green flag is a
pass, a yellow flag indicate minor issues that must be addressed,
and a red flag is a fail. These flags come in two areas: standards
and requirements of practice (ROP). Red flags in an ROP could
lead to a facility losing its accreditation.
However in reality that is not very likely, said Cathy Covino,
Senior Director - Quality & Risk Management. As part of
the process, Accreditation Canada sends the Health Sciences
Centre a selfassessment survey so that it can internally review
its practices. This provides what is called the Quality Performance
Road Map, giving the facility’s “score”
based on the flag system, allowing the Health Sciences Centre
to address any issues before the actual accreditation visit.
“The questions they ask us during accreditation are
the same ones we see on these self-assessment tools, so there
are no surprises,” Covino said.
During the accreditation visit, the surveyors review different
areas of the Health Sciences Centre. One exercise called a
“tracer” follows a patient’s path through
the system or an administrative process from start to finish.
Clinical tracers are usually based on administrative records
like admission reports, diagnostic tests, treatment, etc.
However if the patient is still in the Health Sciences Centre,
the surveyor may ask the patient and family about their care.
“It’s an opportunity for us to find out what
we can do better, and to make sure we keep on improving our
level of care,” Ferguson said.
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