By Cecilia Nasmith
Important visitors are at Northumberland Hills Hospital this week from Monday through Thursday – three peer surveyors from Accreditation Canada.
While the work required to participate in this internationally recognized quality-improvement program is rigourous, the hospital's press release said, the benefits of the accreditation journey are many.
“Every member of our team is committed to quality and safety in health-care delivery,” NHH President and Chief Executive Officer Susan Walsh stated.
“Accreditation through Accreditation Canada's Qmentum program is not a one-time affair – it is actually a journey over many years, and an on-going opportunity to continuously assess our organization's processes against evolving standards of excellence to identify what we are doing well and what may need to be improved in the future.”
Walsh – an Accreditation Canada surveyor herself who has been part of the experience from both sides – noted that such accreditation is a voluntary process in which many Ontario hospitals choose to participate, along with home- and long-term-care providers, community and public-health agencies, mental health and addiction treatment facilities, labs and private clinics.
While these surveys are generally conducted on a four-year cycle, NHH had its last Accreditation Canada survey in 2017, delayed by several years due to the COVID-19 pandemic. This subsequent on-site survey is the latest opportunity for teams throughout NHH to showcase performance against key priority processes, while also highlighting the hospital's resilience through a period of unprecedented local and global change.
The process begins with NHH staff, physicians and volunteers completing a series of self-assessments against Accreditation Canada standards that examine an organization's governance, leadership, risk-management, infection-prevention and -control, and medication-management measures (as well as the quality of care experienced in these care areas).
The on-site survey now taking place is the next step, to be conducted by three trained peer surveyors.
Dr. Gayle Campbell is currently the After Hours Administrator at Orillia's Soldiers Memorial Hospital. She has held a variety of management and administrative positions at several acute-care hospitals in Central Ontario, as well as multiple positions in long-term care. She is also president and owner of a consulting firm that serves the fields of management, policy development, education and quality improvement. An RN with undergraduate degrees in nursing, administration and business, as well as a graduate degree in business administration and a PhD in administration, Campbell maintains part-time faculty position in the post-diploma RN degree program at Laurentian University.
Andrew Williams is President and Chief Executive Officer of the Huron Perth Healthcare Alliance, having previously held senior positions at Stratford General Hospital, Seaforth Community Hospital and Ottawa Civic Hospital. With an honour Bachelor of Science in biology and a Master of Health Services Administration from Dalhousie University, he currently sits on the Ontario Hospital Association's Small, Rural and Northern Leadership Council, is a member of the Southwest Local Health Integration Network's Health Systems Leadership Council (co-chairing its Hip Fracture and Emergency Department/Mental Health Access and Flow Steering Committee), and is a member of the Huron Perth Provider's Council.
Donnalene Tuer-Hodes, a front-line staff worker for more than 20 years, now holds the position of Chief Nursing Executive and Program Director of Surgery, Maternal Child and Medical Device Reprocessing Department with the Huron Perth Healthcare Alliance. With both Bachelor and Masters of Science nursing degrees and an Advanced Nurse Practitioner diploma, she is certified as a Legal Nurse Consultant. She has taught for the post-RN degree program for Ryerson University for 10 years and was a research consultant in rural health for McMaster University. She has been an Accreditation Canada surveyor for 12 years.
The work of these three surveyors will focus on the processes used to deliver care (as opposed to individual health-care providers), and the whole organization is involved – from front-line staff and volunteers to board members, patients and families.
Following the on-site surveys, the team will submit a preliminary report to NHH and to Accreditation Canada. Accreditation Canada will then examine the report before issuing a final report and accreditation decision to NHH (Accredited, Accredited With Commendation, or Accredited with Exemplary Standing). On NHH's end, the survey results will provide guidance regarding areas of success and areas where improvements can be made.
“Accreditation is not something with a start and a finish – it is a continuous process,” NHH Board Chair Elizabeth Selby said.
“Quality oversight is at the heart of our board's responsibilities, and we applaud the team's participation in the Accreditation Canada process through the years.
“Everyone at NHH strives to deliver exceptional patient care every time, but no organization is exceptional all the time. We know there is always room for improvement,” Selby said.
“What is unique about this process is that it reviews compliance against Required Organizational Practices related to high-risk areas across the entire organization, not simply one or two programs.
“The board looks forward to learning how NHH is doing in 2022 in comparison to these evolving practices, and sharing this with our community. It's an assessment that is arguably all the more important in light of the exceptional strain of recent years.”
