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Accreditation 2005

“Competence, Professionalism and a Caring Environment”

After an exhaustive examination of both the BGH and Willett sites, the BCHS was awarded a full 3 year accreditation in April of 2005.

They were impressed and found that our organization is oriented towards the needs of its clients. Being in the midst of construction can complicate patient care. The surveyors understood this and termed it “happy noise” because of its eventual outcome. The words the surveyors consistently heard from patients and community partners about staff were, “communicative, inclusive and just phenomenal.”

Ambulatory Care
“Great,” was the operative word used in describing this team. The “great,” new, beautiful dialysis expansion able to accommodate 80 more patients was mentioned as was the “great” diabetic programs. Patients, clients and community partners all felt that staff had competence, professionalism and provided a caring environment.

CCC
They were complimented on a close collaboration with patients, families and community providers. Danielle mentioned the “nice feeling” that she got from the team. They were commended for their excellent processes in transitioning patients. Although recognizing that the team is in transition, Palliative Care initiatives were commended.

Critical Care
Research projects with McMaster were seen as commendable. The team is highly functioning almost to the level of an advanced, tertiary centre. The team got a “blue ribbon,” for being on top of their game. Patients were very complimentary, saying they truly felt well cared-for.

Emergency Services
The team proved its strength through its infection control procedures with SARS being mentioned. Its ability to communicate with patients about the tests being done on them is excellent and they got three cheers from the surveyors for their multi-language brochure.

Environmental Services
This team is a “pillar” in the organization despite having undergone significant changes. Occupational health issues presented challenges while under construction but the team managed “minimal interruption to services,” never having to put cold sandwiches on a patient's plate. The hiring of an Infection Control Specialist allowed the organization to make remarkable strides and the cross training provided to Bio-Medical Staff was termed “awesome.”

Human Resources and Development
Physician Recruitment was seen as a great success and the move forward towards a 70/30 split between full and part time nurses was encouraging. The new “Leadership 101” program was put forward as an excellent program for staff development. Despite the challenges created by construction, on the whole the surveyors felt that staff relations were very harmonious and commended them for the surveys they undertook. They even mentioned our “visible and approachable physicians.”

Information Management
This team was commended for operating on a very high level, “better than many larger organizations.” Library Services was singled out for the high value placed on it and the increasing number of patients and families taking advantage of this service.

Leadership
Calling them a “dynamic group” the surveyors were impressed with how all decisions are matched with the mission, vision and values, saying, “Even though there are two separate boards, they share common goals and are able to harmonize the work that needs to commence.” The establishment of the Wellness, Healthcare and Integration portfolio was seen as a strong point and extremely important to do. The organization was complimented on the work done on the population profile and its use in decision making.

Maternal/Child
Referring to its many moves while under construction, surveyor, Danielle Swerhone, recognized the team for its creative and innovative use of c-section space. The planning of Labour Delivery and Recovery rooms was viewed as a significant move forward. As well, the asthma clinic was commended for its dramatic reduction of visits to the Emergency Department. Referring to the discharge processes of new mothers, Danielle said the department is doing great things, mentioning vaccinations and car seat checks.

Medical Care
Saying that this team had mutual respect and support for each other, they commended them for setting up Unit Action Councils. Being a physician himself, Dr. Andrew Padmos appreciated the pharmacist's “physician writing contest” saying that he couldn't believe that anyone could win it. He mentioned the new stroke strategy as a “signal” program on the leading edge of patient care. They were encouraged that the pain management program was being disseminated throughout the organization.

Mental Health
This team has done miracles. Dr Pierre Beausejour commented on their ability to manage risk in the older facility. He encouraged us to move quickly on the renovations. They were complimented on their pioneering the use of the WHO assessment scale. Their development of an outpatient booking system has resulted in the elimination of the waiting list and managed patient flow with very positive results.

Rehabilitation
Rehab Inc. was recognized as a very complimentary service that fits in fine with an organization of our size. The Physiotherapists, Occupational Therapists and therapies in general were termed, “awesome.”

Surgical Care
In a very complex environment the team has a good mix of technology and people skills. The OR and utilization management was seen as very good and the team was recognized for being innovative and creative in their research projects. The clinical care pathways after surgical care were commended for being very good.

In the end, the surveyors felt that we have a strong and evolving culture of quality improvement. In particular, they felt that what they received in the self assessments and what they saw in their visit were very congruent.