On-site Survey Debriefing CASA Child, Adolescent and Family Mental Health 21/10/2013 - 24/10/2013

On-site Survey DebriefingCASA Child, Adolescent and

Family Mental Health21/10/2013 - 24/10/2013

On-site Survey DebriefingCASA Child, Adolescent and

Family Mental Health21/10/2013 - 24/10/2013

© Accreditation Canada/Agrément Canada

The On-Site SurveyThe On-Site Survey

A comprehensive review of governance, leadership, clinical programs and services

Incorporates multiple sources of evidence Observations from tours and direct care

provision Discussions with staff, clients, families, board,

community partners, and stakeholders Review of documentation

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© Accreditation Canada/Agrément Canada 3

Overview of the On-Site Survey Overview of the On-Site Survey

21/10/2013 - 24/10/2013 Genevieve Corbin Doreen Fey Kevin Hayes


Preliminary ResultsPreliminary Results

The results presented here are preliminary.

Results will be reviewed by Accreditation Canada for internal consistency. Therefore, it is recommended that these results be reserved for internal use.

The Accreditation Report, issued by Accreditation Canada within 10 days, will provide final results and the accreditation decision.


Overall StrengthsOverall Strengths

Innovation ie new Front Door Services

Effective Outreach

Generosity of Spirit

Organizations Report Card and Targets


Overall Areas for ImprovementOverall Areas for Improvement

Leadership Development

Infection Prevention and Control practices

Implement medication rec fully across programs

Policy Development cycle


Overview by Quality DimensionOverview by Quality Dimension

Quality Dimension Met

Unmet

N/A Total

Population Focus (Working with communities to anticipate and meet needs) 31 6 0 37

Accessibility (Providing timely and equitable services) 18 1 0 19

Safety (Keeping people safe) 104 8 20 132

Worklife (Supporting wellness in the work environment) 57 7 1 65

Client-centred Services (Putting clients and families first) 50 0 1 51

Continuity of Services (Experiencing coordinated and seamless services) 12 0 0 12

Effectiveness (Doing the right thing to achieve the best possible results) 182 33 15 230

Efficiency (Making the best use of resources) 26 1 0 27


Overview by Standard SectionOverview by Standard Section

Standard Section Met Unmet

N/A Total

Governance 72 6 0 78

Leadership 112 27 1 140

Infection Prevention and Control 54 17 30 101

Customized Managing Medications 46 1 5 52

Community-Based Mental Health Services and Supports Standards 134 1 0 135

Telehealth Services 62 4 1 67


High-priority criteria focus on …High-priority criteria focus on …

Patient safety Ethics Risk management Quality improvement

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Patient safetyPatient safety

Strengths Client and family education Hand Hygiene Audits

Areas for improvement

Report on progress to staff, leaders and Board


EthicsEthics

Strengths Staff survey to understand the importance of

ethics process Research ethics framework has been

developed

Areas for improvement: Complete the action plan Develop framework


Risk managementRisk management

Strengths Job hazard analysis Health and safety audit

Areas for improvement Complete the risk assessment process Develop risk framework and risk mitigation

plan CASA Center


Quality improvementQuality improvement

Strengths Focus on consultation during improvement

activities Evaluation at a glance

Areas for improvement Integrate the framework Prioritize improvement projects


Reaching an accreditation decisionReaching an accreditation decision

Surveyor findings are forwarded to Accreditation Canada

Decision is made by the Accreditation Decision Committee, in collaboration with surveyors as required

Accreditation Decision Committee ensures consistency in application of decision guidelines

Decision guidelines include compliance with standards criteria, Required Organizational Practices, and instrument thresholds

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Accreditation AchievementAccreditation Achievement

Participating in accreditation is a significant achievement

Demonstrates commitment to quality and safety

Best results achieved through continued integration of accreditation into ongoing quality initiatives

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Next StepsNext Steps

Accreditation Report, with accreditation decision, issued within 10 days

Over the next five months, submit evidence of action taken to address gaps

Continue to action opportunities for improvement


Contact usContact us

Accreditation Canada

1150 Cyrville RoadOttawa, ON Canada K1J 7S9

Tel: 1-800-814-7769 or 613-738-3800Fax: 1-800-811-7088 or 613-738-3755

www.accreditation.ca

Accreditation Canada does not accept responsibility for the accuracy of this material if is presented by anyone other than an authorized Accreditation Canada representative.

The leader in raising the bar for health quality

The leader in raising the bar for health quality

Le leader qui hausse la barre en matière de qualité de santéLe leader qui hausse la barre

en matière de qualité de santé

Documents

On-site Survey Debriefing CASA Child, Adolescent and Family Mental Health 21/10/2013 - 24/10/2013