Hi everyone,

The accreditation team will be at HSC next week, with a specific visit set for the main OR and to the Gyne OR and labour floor. These visits to our areas are scheduled for May 26th. The accreditation team may return to any area that they have previously visited, so we need to be prepared to be audited potentially any day next week.

The accreditation team will be following pre-selected patients through their surgical journey. If the accreditation team comes to your room, they can ask to see your charting and inspect your work area to ensure that controlled medications are locked securely in the safe.

As always, there will be an expectation that no one brings food or beverages into the OR, always wear a mask while in the OR, and keep ear pods out of ears. Everyone should be seen as compliant with the standards of excellence expected of us.

A few important documents are attached, all of which can be found on the Quality and Accreditation Share Point site within the resources - SHSDO QI and Accreditation - Home

Pay special attention to the "Making it Real" document which contains some sample responses to potential questions asked by the accreditors.

Documents include:

Our surveyor’s Bio (Penny)
The sequence and list of required organizational practices (ROPs) being audited
High level schedule of all site visits -detailed
Med Management prep checklist (basic) – helpful quick tips

The poster (snapshot below) to be shared with patients when on site provides information on how they can respond to surveyors if engaged. (Key takeaways in yellow box)

These will be laminated and on MS3 Day Surgery and pre/post-op area.

There has also been communication shared with admitting to share similar information with patients/families as they arrive.

The areas within the Surgery & Surgical Processes programs included in this year’s sequence 2 visit are:

MDR, Adult OR, GH-5, & GD-3

Quick shot:

MDR=Monday

Adult OR=Tuesday (a.m.)

GH-5=Tuesday (p.m.)

GD-3=Thursday

*NOTE: Organ, Tissue & Transplant is also being audited on the Tuesday, so they may or may not include the OR during this tracer but it is always possible.

This would include deceased and living donors.

Also, highlighted are the specific Standard sets and ROPs within those standards that apply to the OR and will be audited (also in attachment above-but here is a snapshot):

Areas of particular focus based on work over the last year at the site and discussion within working groups related to the ROPs would include:

SSCL
Infusion Pump Safety
Med Rec, Do-not-Use abbreviations, & high-alert medications (really anything med management related, especially storage and med rooms)
VTE
Suicide Prevention
Reprocessing/IP&C; and
Hand Hygiene (this is a big one) but overall IP&C compliance has been a big focus

Much of the work done within these groups was and has been driven from RL data, specifically if there was a previous CI. (i.e.: suicide prevention was a big one for this reason).

Thank you for your attention to this. Please reach out with any questions.

Renate and Marshall