Accreditation - June 23 to 25, 2008

In order to maintain and improve the quality of care and service Baycrest delivers, we will participate in an independent evaluation by Accreditation Canada, a voluntary, non-profit, non-government organization dedicated to improving the quality and safety of health services. While it is not mandatory in Ontario, most health care providers in Canada must be accredited to receive funding and support. The accreditation process gives us an external, objective evaluation of our performance as an organization and enables us to compare our performance with our peers across the country.

Here are some frequently asked questions and answers which may be helpful to Baycrest clients and their families

When does accreditation begin?
The accreditation process actually began in September 2007. Baycrest staff, physicians and volunteers completed questionnaires which provided preliminary data for the accreditation process. Accreditation Canada (formerly the Canadian Council Health Services Accreditation) then provided Baycrest with a “roadmap” which helped to identify areas where we either need to clarify how we deliver services or where we need to develop action plans to improve the way we deliver services.

The surveyor visits are the next step in the process. Accreditation Canada has close to 530 surveyors working in partnership with health services organizations to identify strengths and areas requiring improvement. Survey visits are a valuable opportunity for health professionals to seek and exchange information with peers in the field. Accreditation is about learning from leaders and sharing expertise.

The evaluation will examine the care and services provided and will be carried out by a team of experienced health care professionals. These ‘surveyors’ will meet with staff members of Baycrest Hospital and the Apotex Centre Jewish Home for the Aged from June 23 to June 25.

What is tracer methodology?
Tracer methodology is an evaluation method in which surveyors select a patient, resident or client and use that individual’s record as a roadmap to move through Baycrest processes to assess and evaluate the organization’s compliance with selected standards and the organization’s systems of providing care and services. Likened by some to a safety walk around, a tracer follows the selected client through the entire continuum of care. This is an interactive evaluation technique that includes direct observation, individual and group interviews, focus groups, tours, and documentation review.

Are the surveyors going to look at my parent’s health records? How does that help Baycrest?
Prior to the surveyor visit, Baycrest will obtain permission from clients or their substitute decision makers to allow the surveyors to review their health record. No information will be recorded about Baycrest clients or their family members.

The surveyors will review the health records of a number of clients. Review of these health records helps the surveyors to assess the coordination of service provision to clients and the completeness of clinical documentation. Surveyors will maintain the confidentiality of all individual health records.

Will the surveyors ask me anything as a family member?
At Baycrest, families are a valuable part of the care team. As such, family members may be approached by the surveyors to offer their opinions and more information and to provide feedback concerning the care their loved one received.

Surveyors will interview Baycrest staff members about how they do their jobs, how they provide care and service to our patients, including nurses, physicians, social workers, housekeepers, pharmacists, dietitians, and physiotherapists – just to name a few.

I have seen different posters and materials relating to safety at Baycrest. What do they mean to me as a family member?
There are 10 themes that have been displayed on the diorama on the first floor (between the birdcage and the WA café), on posters at the entrances and in other materials. These are the top 10 priorities for Baycrest. These materials have been designed to help all staff members, private companions, volunteers, clients and families learn what to do in these situations.

However, it does not stop there. There may be other issues which relate specifically to your relative, such as elder abuse, skin integrity, incontinence, transfer of information and follow-up care, to name a just few. Please speak with the unit director or program director on your relative’s floor about the issues that you feel are important to you and your family, or if you require any further information regarding accreditation.