Accreditation Report. Quality Improvement Plan & Benchmarking Data. Prepared for St. Joseph s Villa of Sudbury

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2 Report Quality Improvement Plan & Benchmarking Data Prepared for St. Joseph s Villa of Sudbury

3 Decision Three-Year Expiration: November 30, 2018 Organization St. Joseph s Villa of Sudbury () 1250 South Bay Road Sudbury ON P3E 6L9 CANADA Three-Year Organizational Leadership Jo-Anne Palkovits, Administrator Dates October 29-30, 2015 Team Avanthi Goddard, BBA Hon., Dip Adult Ed., Administrative or Bruce Hartshorne, CASP, Program or Programs/Services ed Person-Centred Long-Term Care Community Governance Standards Applied Previous November 1-2, 2012 Three-Year

4 Summary Areas of Strength St. Joseph s Villa of Sudbury () has strengths in many areas. The person-centred philosophy is led, embedded, and implemented through the mission and values of the organization that has a strong and long spiritual history. The volunteer program has gone from 35 volunteers to approximately 120 volunteers in less than three years. The effective strategies of engaging the community; the strong reputation in the city and region of the program and its parent organization; and the family-like, respectful, and engaging work environment have contributed to the success of volunteer recruitment and retention. The board of directors implements a framework of governance that is well supported by its by-laws and extensive policies, and demonstrates an effective governance model that leads and is passionate about the mission, values, and vision. The staff members at the organization have a strong team culture that is supportive of each other and person focused. This is evidenced by the positive energy and innovative ways of engaging persons served daily in having fun, enjoying coming to work, and feeling appreciated even through a difficult workload and financial challenges. There are many examples of quality improvement initiatives that demonstrate effectiveness and efficiency of both the business processes and improving the living experience, safety, and outcomes of persons served. These include, but are not limited to, the improved safety strategies for a growing population with dementia, improved clinical scores for wound management, falls, incontinence, and building and space utilization. Peer evaluation and auditing techniques have been used to ensure that quality standards are being met. It is evident that the management seeks to hire highly motivated and qualified employees and then encourages them to use their skills and creativity to come up with solutions for effectiveness, efficiency, and business function. The staff members have responded well to the encouragement by providing many new initiatives in the areas of supplies savings, work order control, cost and control accounting, etc. Infection control practices are very diligent as evidenced by the fact that the home has managed to have only one outbreak in the past year that closed the program to visitors for only a short duration. Innovative and leading-edge programs and frameworks have been implemented that have and will continue to create quality improvements. In addition, the Quality Framework and its mapping from operations to strategic direction is a unique system of supporting the achievement of quality goals and targets through the use of an accountability framework of committees that is linked from operational committees to committees of the board of directors who are accountable for the mission and vision of the organization. The organization has been recognized for this unique system by Health Quality Ontario; was asked to present at the Health Quality Transformation 2013 conference; and was visited by the Minister of Health and Long-Term Care, Ontario, to acknowledge the innovative way the organization has engaged the board and its managers in being accountable for quality improvement and achieving its targets. St. Joseph's Villa of Sudbury Report 1

5 Areas for Improvement should seek improvement in the following areas. The emergency plan does not identify essential services and the continuation of essential services. The organization is urged to update written emergency procedures to address the identification and the continuation of essential services. Only evacuation and fire procedures have been tested annually on all shifts. The organization is urged to conduct unannounced tests of all emergency procedures on each shift. Tests should be analyzed for performance that addresses areas needing improvement, actions to be taken, results of performance improvement plans, and necessary education and training of personnel, and should be evidenced in writing. The organization uses analysis of each incident to identify corrective and preventative action, but does not trend critical incidents over a long enough time period to identify trends and is therefore urged to address trends in its annual written analysis of all critical incidents. The program should review its scope of services at least annually to ensure that capacity and competency of the organization are able to meet the changing and complex needs of the persons served. Although the organization was able to verbalize how refunds are to be handled, the person s written agreement did not reflect the practice. The person s written agreement should contain information regarding the refund policies. The program s written philosophy of health and wellness should address aging in place. Although the effectiveness of education is reviewed and educational plans and content are changed as needed, performance targets have not been established. The organization should measure the effectiveness of the learning techniques used in the learning environment for personnel against a performance target. The organization should provide documented competency-based training for personnel at orientation and at regular intervals that includes the gathering of information about the person s history, current status, important memories, favourite stories, daily routines, comfort/reminiscence objects, and people of importance. Although the organization has a policy that addresses visiting hours and this information is included in the handbook for persons served, the policy indicates that visiting 24/7 is only by exception. The organization should develop policies and written procedures that allow the opportunity for the persons served to receive visitors 24 hours a day, if desired and the visit does not infringe upon the health, safety, or rights of any persons served and not just by exception. 2 St. Joseph's Villa of Sudbury Report

6 Decision St. Joseph s Villa of Sudbury has earned a Three-Year. On balance, has demonstrated substantial conformance to the CARF standards and has used the standards to improve effectively over time. The organization has a well-informed leadership team that implements best practices and leads the industry in the region with cutting-edge and innovative ways of being effective and efficient to its mission. The organization has a culture of quality improvements at all levels. The organization appears to have the commitment and resources to address the opportunities for improvement noted in this report and is encouraged to continue to use the CARF standards to further enhance the provision of its services. St. Joseph's Villa of Sudbury Report 3

7 Consultation Section 1. ASPIRE to Excellence A. Leadership The leadership is encouraged to expand its assessment and learning of the organization s cultural competency and diversity gaps that demonstrate its awareness of the diversity of the key stakeholders. The organization has some written procedures on how to deal with allegations of violations of ethical codes in documents, such as union contracts and board by-laws. These procedures do not relate to the ethical codes directly and the procedure is not easily accessed should a violation occur. The organization may want to include the violation procedure with the code of ethics and conduct documents. E. Legal Requirements The staff and volunteer paper format files are maintained in file folders. The sections are divided by loose sheets of paper and the documents are loosely filed and not secured, with a potential of being lost or missed during a review process. The organization may want to consider a way to secure the paper through mechanisms such as clips or fasteners to ensure the security of the paper files. J. Technology The organization may want to include the disaster recovery preparedness plan with the emergency manual to ensure consistency in direction and ease of access for leading the implementation of the emergency plan. Consultation does not indicate non-conformance to standards but is offered as a suggestion for further quality improvement. 4 St. Joseph's Villa of Sudbury Report

8 Standards Conformance This section of the Report displays the specific reasons for any partial or non-conformance to standards identified as a result of the survey. The standards listed in this section are addressed in the organization s Quality Improvement Plan, which can be accessed at customerconnect.carf.org. Below are the possible reasons for partial or non-conformance to standards, along with an explanation of why each reason is cited. To receive the information contained in this section in an alternate format, please contact editing@carf.org. Reason for partial or non-conformance Credentials inadequate Data or information necessary to address conformance not collected and/or evaluated Documentation inadequate Effort not comprehensive Financial ratio calculation below the median Forms inadequate Frequency inadequate Information not communicated understandably Involvement by appropriate person(s) inadequate Non-compliance with law, regulation, or other rule Policy/plan/procedure/practice not consistently implemented Policy/plan/procedure/practice not developed Policy/plan/procedure/practice not implemented Policy/plan/procedure/practice recently implemented Training inadequate Evidence of conformance inadequate Is cited: When a standard element requires that an individual possess a specific credential or level of credential, the specific credential is not possessed, or the credential possessed is below the specified level. When the issue addressed by the standard element has not been considered and, consequently, the information necessary to address conformance has not been collected and/or evaluated in connection with the issue addressed. When a standard element requires documentation or that documentation contain specific information, the documentation either does not exist or does not contain the specific information. When a standard element requires an activity to occur, the performance of the activity is insufficient to address the full scope of the activity. When the standard element rating is based on the calculation of a specific financial ratio, such ratio is below the 50th percentile. When a standard element requires use of a specific form or that the form contain specific information, the form is not used or does not contain the specific information. When a standard element requires that an activity occur with a specific frequency or some unspecified regularity, the performance of the activity does not occur, occurs less frequently than required, or occurs less frequently than appropriate if regularity unspecified. When a standard element requires that information be shared with certain persons, the information is either not shared or not shared in a manner that allows for comprehension by the recipient. When a standard element requires the involvement of certain persons, those persons are either not involved or not involved in a sufficient manner. When a standard element requires compliance with a legal requirement or a process for achieving legal compliance, sufficient evidence of compliance or the compliance process is not demonstrated. When a standard element requires a policy/plan/procedure/practice, it exists but the actual performance does not occur with sufficient regularity to be deemed standard operating procedure. When a standard element requires a policy/plan/procedure/practice, it is not in existence. When a standard element requires a policy/plan/procedure/practice, it exists but there is no actual performance. When a standard element requires a policy/plan/procedure/practice, it exists but the actual performance has not been in place for sufficient time to establish a track record. When a standard element requires that certain training occur, it either does not occur or does not occur with sufficient regularity to be deemed standard operating procedure. When the requirement of a standard element is not satisfied, or is inconsistently satisfied and no other reasons apply. St. Joseph's Villa of Sudbury Report 5

9 Standard Number Standard Text Reasons for Partial or Non-conformance 1.H.5.c.(7) There are written emergency procedures: That address, as follows: Identification of essential services. Credentials inadequate Data or information necessary to address conformance not collected and/or evaluated Documentation inadequate Effort not comprehensive Financial ratio calculation below median Frequency inadequate Information not communicated understandably Involvement by appropriate person(s) inadequate Non-compliance with law, regulation, or other rule Policy/plan/procedure/practice not consistently implemented Policy/plan not developed Procedure/practice not developed X X Policy/plan/procedure/practice not implemented Policy/plan/procedure/practice recently implemented Training inadequate Evidence of conformance inadequate 1.H.5.c.(8) There are written emergency procedures: That address, as follows: Continuation of essential services. X X 1.H.7.a.(1) Unannounced tests of all emergency procedures: Are conducted at least annually: On each shift. X X 1.H.7.c.(1) Unannounced tests of all emergency procedures: Are analyzed for performance that addresses: Areas needing improvement. X 1.H.7.c.(2) Unannounced tests of all emergency procedures: Are analyzed for performance that addresses: Actions to be taken. X 1.H.7.c.(3) 1.H.7.d. Unannounced tests of all emergency procedures: Are analyzed for performance that addresses: Results of performance improvement plans. Unannounced tests of all emergency procedures: Are evidenced in writing, including the analysis. X X X 1.H.10.a. A written analysis of all critical incidents is provided to or conducted by the leadership: At least annually. X X 2.A.1.c. Each program/service: Reviews the scope of services at least annually and updates it as necessary. X 2.A.10.e.(7) Based on the scope of services, there is a written agreement: That contains information regarding: Refund policies. X 2.A.32.b. Based on its scope of services, the program has a written philosophy of health and wellness for the persons served that: Addresses aging in place. X 2.A.42.c. Leadership fosters a continuous learning environment for personnel that: Measures the effectiveness of the techniques used in the learning environment against a performance target. X 6 St. Joseph's Villa of Sudbury Report

10 Standard Number Standard Text Reasons for Partial or Non-conformance 2.A.51.a.(1) The organization provides documented competency-based training for personnel, as appropriate to their roles: At: Orientation. Credentials inadequate Data or information necessary to address conformance not collected and/or evaluated Documentation inadequate Effort not comprehensive Financial ratio calculation below median Frequency inadequate Information not communicated understandably Involvement by appropriate person(s) inadequate Non-compliance with law, regulation, or other rule Policy/plan/procedure/practice not consistently implemented X Policy/plan not developed Procedure/practice not developed Policy/plan/procedure/practice not implemented Policy/plan/procedure/practice recently implemented Training inadequate Evidence of conformance inadequate 2.A.51.a.(2) The organization provides documented competency-based training for personnel, as appropriate to their roles: At: Regular intervals. X X 2.A.51.b.(12)(a) The organization provides documented competency-based training for personnel, as appropriate to their roles: That includes: Gathering information about the person served in the following areas: History. X X X 2.A.51.b.(12)(b) The organization provides documented competency-based training for personnel, as appropriate to their roles: That includes: Gathering information about the person served in the following areas: Current status. X X X 2.A.51.b.(12)(c) The organization provides documented competency-based training for personnel, as appropriate to their roles: That includes: Gathering information about the person served in the following areas: Important memories. X X X 2.A.51.b.(12)(d) The organization provides documented competency-based training for personnel, as appropriate to their roles: That includes: Gathering information about the person served in the following areas: Favorite stories. X X X 2.A.51.b.(12)(e) The organization provides documented competency-based training for personnel, as appropriate to their roles: That includes: Gathering information about the person served in the following areas: Daily routines. X X X 2.A.51.b.(12)(f) The organization provides documented competency-based training for personnel, as appropriate to their roles: That includes: Gathering information about the person served in the following areas: Comfort/reminiscence objects. X X X St. Joseph's Villa of Sudbury Report 7

11 Standard Number Standard Text Reasons for Partial or Non-conformance 2.A.51.b.(12)(g) The organization provides documented competency-based training for personnel, as appropriate to their roles: That includes: Gathering information about the person served in the following areas: People of importance. Credentials inadequate Data or information necessary to address conformance not collected and/or evaluated Documentation inadequate Effort not comprehensive Financial ratio calculation below median Frequency inadequate Information not communicated understandably Involvement by appropriate person(s) inadequate Non-compliance with law, regulation, or other rule Policy/plan/procedure/practice not consistently implemented Policy/plan not developed Procedure/practice not developed Policy/plan/procedure/practice not implemented Policy/plan/procedure/practice recently implemented Training inadequate X X X Evidence of conformance inadequate 2.B.10. Policies and written procedures allow the opportunity for the persons served to receive visitors 24 hours a day, if desired and the visit does not infringe upon the health, safety, or rights of any persons served. X 8 St. Joseph's Villa of Sudbury Report

12 Benchmarking This section of the Report benchmarks your organization s conformance to standards. By comparing strengths and areas for improvement with various comparator groups, benchmarking encourages your organization to improve effectiveness, efficiency, satisfaction, and access. This information should also stimulate discussions among stakeholders focused on better meeting the needs and preferences of the persons served. In addition, benchmarking: Encourages a culture of continuous evaluation and improvement. Accelerates understanding of and agreement on areas for improvement. Helps prioritize improvement opportunities. Shifts internal thinking toward a focus on outcomes. Provides a reference to increase performance expectations. Motivates your team to work collaboratively to surpass benchmarks. This report provides benchmarks (mean % of conformance) for each section of the ASPIRE to Excellence quality framework. * When available, benchmark comparison groups include: All surveyed organizations. All surveyed organizations in the same primary CARF customer service unit. ed organizations with the same ownership type. ed organizations in the same geographic region. ed organizations with similar number of persons served annually. ed organizations with similar staff size. In addition, standards conformance for each organization undergoing resurvey is benchmarked against its previous survey in all standards areas. Benchmark Comparison Groups Primary area of accreditation: Aging Services (AS) Ownership type: Private, Not for Profit Geographic region: Canada ON Staff size (FTEs): Persons served annually: To receive the information contained in this section in an alternate format, please contact editing@carf.org. * Excluding Governance. St. Joseph's Villa of Sudbury Report 9

13 All surveyed organizations A: Assess the Environment Leadership CARF Three-Year CARF One-Year 88.7% 98.1% Nonaccreditation 79.3% S: Set Strategy Strategic Planning CARF Three-Year CARF One-Year Nonaccreditation 46.3% 81.7% 98.3% 10 St. Joseph's Villa of Sudbury Report

14 All surveyed organizations continued P: Persons Served and Other Stakeholders - Obtain Input Input from Stakeholders CARF Three-Year CARF One-Year Nonaccreditation 60.0% 83.4% 99.8% Legal Requirements CARF Three-Year CARF One-Year Nonaccreditation 99.5% 94.7% 88.7% St. Joseph's Villa of Sudbury Report 11

15 All surveyed organizations continued Financial Planning and Management CARF Three-Year CARF One-Year Nonaccreditation 69.2% 91.7% 99.2% Risk Management CARF Three-Year CARF One-Year 79.7% 97.4% Nonaccreditation 56.0% 12 St. Joseph's Villa of Sudbury Report

16 All surveyed organizations continued Health and Safety CARF Three-Year CARF One-Year 84.0% 95.6% 96.7% Nonaccreditation 74.3% Human Resources CARF Three-Year CARF One-Year 87.5% 97.6% Nonaccreditation 72.9% St. Joseph's Villa of Sudbury Report 13

17 All surveyed organizations continued Technology CARF Three-Year CARF One-Year 85.2% 99.0% Nonaccreditation 63.8% Rights of Persons Served CARF Three-Year CARF One-Year Nonaccreditation 98.6% 93.4% 86.5% 14 St. Joseph's Villa of Sudbury Report

18 All surveyed organizations continued Accessibility CARF Three-Year CARF One-Year 74.7% 96.3% Nonaccreditation 50.5% R: Review Results Performance Measurement and Management CARF Three-Year CARF One-Year Nonaccreditation 41.9% 70.0% 97.3% St. Joseph's Villa of Sudbury Report 15

19 All surveyed organizations continued E: Effect Change Performance Improvement CARF Three-Year CARF One-Year Nonaccreditation 22.0% 41.7% 92.9% 16 St. Joseph's Villa of Sudbury Report

20 Other benchmarks A: Assess the Environment Leadership Aging Services Private, Not for Profit Ontario 95.7% 96.8% 95.7% 100 to 499 FTEs 97.8% 100 to 499 Persons Served 97.2% S: Set Strategy Strategic Planning Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 96.9% 98.1% 98.1% 99.1% 100 to 499 Persons Served 97.8% St. Joseph's Villa of Sudbury Report 17

21 Other benchmarks continued P: Persons Served and Other Stakeholders - Obtain Input Input from Stakeholders Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 100 to 499 Persons Served 99.7% 99.7% 99.8% 99.9% 99.6% Legal Requirements Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 100 to 499 Persons Served 99.5% 99.3% 99.6% 99.7% 99.5% 18 St. Joseph's Villa of Sudbury Report

22 Other benchmarks continued Financial Planning and Management Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 100 to 499 Persons Served 99.1% 99.3% 99.1% 99.4% 99.1% Risk Management Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 97.4% 96.7% 97.9% 98.2% 100 to 499 Persons Served 97.3% St. Joseph's Villa of Sudbury Report 19

23 Other benchmarks continued 95.6% Health & Safety Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 96.0% 95.8% 95.9% 96.8% 100 to 499 Persons Served 96.3% Human Resources Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 97.3% 97.2% 97.0% 98.1% 100 to 499 Persons Served 97.1% 20 St. Joseph's Villa of Sudbury Report

24 Other benchmarks continued Technology Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 98.6% 98.7% 98.7% 99.5% 100 to 499 Persons Served 98.8% Rights of Persons Served Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 100 to 499 Persons Served 98.3% 98.3% 98.4% 98.6% 98.5% St. Joseph's Villa of Sudbury Report 21

25 Other benchmarks continued Accessibility Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 94.0% 95.6% 95.5% 97.6% 100 to 499 Persons Served 96.4% R: Review Results Performance Measurement and Management Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 100 to 499 Persons Served 99.2% 96.8% 98.3% 98.2% 97.3% 22 St. Joseph's Villa of Sudbury Report

26 Other benchmarks continued E: Effect Change Performance Improvement Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 100 to 499 Persons Served 96.8% 91.1% 94.0% 95.4% 92.5% St. Joseph's Villa of Sudbury Report 23

27 Previous survey A: Assess the Environment Leadership Current Previous S: Set Strategy Strategic Planning Current Previous 24 St. Joseph's Villa of Sudbury Report

28 Previous survey continued P: Persons Served and Other Stakeholders - Obtain Input Input from Stakeholders Current Previous Legal Requirements Current Previous St. Joseph's Villa of Sudbury Report 25

29 Previous survey continued Financial Planning and Management Current Previous 91.8% Risk Management Current Previous 65.6% 26 St. Joseph's Villa of Sudbury Report

30 Previous survey continued Health and Safety Current Previous 95.6% 91.9% Human Resources Current Previous 96.2% St. Joseph's Villa of Sudbury Report 27

31 Previous survey continued Technology Current Previous Rights of Persons Served Current Previous 28 St. Joseph's Villa of Sudbury Report

32 Previous survey continued Accessibility Current Previous R: Review Results Performance Measurement and Management Current Previous St. Joseph's Villa of Sudbury Report 29

33 Previous survey continued E: Effect Change Performance Improvement Current Previous Section 2. Care Process for the Persons Served A. Program/Service Structure Current Previous 98.2% 98.3% 30 St. Joseph's Villa of Sudbury Report

34 Previous survey continued Section 2. Care Process for the Persons Served B. Congregate Residential Programs Current Previous 99.0% Section 3. Program Specific Standards D. Person-Centred Long-Term Care Community Current Previous St. Joseph's Villa of Sudbury Report 31

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