Accreditation Canada lists three Region programs among the nation's best

Report highlights leading practices as well as areas for improvement

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About Accreditation Canada

Why accreditation matters

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Read about the Region's equity strategy

Winnipeg Health Region
Published Friday, January 7, 2011

An innovative Winnipeg Health Region program to immunize people at high risk for influenza has been singled out as one of the best of its kind in Canada.

The Region's equity immunization program was one of three to receive leading practice designations from Accreditation Canada, a not-for-profit, independent organization that has been driving quality health services for more than 50 years. A staff training workshop in mental health and the Geriatric Assessment Program Teams (GPATs) also received leading practice designations.

It's the second year in a row that the Region has received multiple leading practice designations. Last year, four Regional programs were recognized as having leading practices.

"Leading practices are commendable or exemplary organizational practices that demonstrate high quality leadership and service delivery," Accreditation Canada said in its 2010 report. "Accreditation Canada considers these practices worthy of recognition as organizations strive for excellence in their specific field, or commendable for what they contribute to health care as a whole."

A dozen Accreditation Canada surveyors from across Canada visited the Winnipeg Health Region last November to conduct a review of several programs, including long-term care, adult mental health, population and public health and rehabilitation. In doing so, surveyors visited 45 health-care facilities, observing practice, tracing a client's journey of care, reviewing case files and interviewing staff, clients and community partners.

In reviewing the programs, Accreditation Canada noted that 664 criteria were assessed by surveyors. Of these, 91 per cent of the criteria were met, according to surveyors, while seven per cent were unmet. The remaining two per cent did not apply to the programs under review in 2010. The report means that the Region will maintain its accreditation status in the programs reviewed.

Arlene Wilgosh, President & CEO of the Winnipeg Health Region, said the report provides important feedback on what the Region is doing well and what it can do to improve the delivery of care.

"To have some of our programs singled out as being among the best in Canada is gratifying for us as a Region and a credit to the women and men who are delivering care in this community," said Wilgosh. "Clearly, the people and organizations that make up the Region are committed to quality and safety, continuous learning and improvement."

Kaaren Neufeld, Chief Quality Officer for the Winnipeg Health Region, said the accreditation process is a "powerful accountability tool" to help the Region deliver better care. "Accreditation Canada's programs give us the opportunity to evaluate our performance using national standards of excellence. These standards examine all aspects of our work from patient safety and ethics, to work life and partnering with the community. The process also helps us to act on daily opportunities to make positive improvement in care and service."

Here is what Accreditation Canada had to say about the three leading practices:

Equity strategy - influenza immunization

An "equity strategy" was carefully assessed, integrated into the pandemic plan, then implemented to improve access to the influenza vaccine for hard-to-reach populations. This strategy included reducing barriers to access at mass clinics, community outreach clinics in venues both familiar with and new to immunization services, enhanced home-bound immunization services, enhanced interpreter and translation services, the use of grassroots promotion within hard-to-reach populations, and providing immunization along with other services. Commitment to the strategy created an environment that allowed for the creative use of resources to overcome systematic barriers to immunization in hard-to-reach populations. Lessons learned from this approach provide a solid foundation on which to improve immunization services for hard- to-reach populations in the future.

Co-occurring disorders multi-agency staff education workshops

The workshops have had a significant impact in improving the competencies of staff to work with persons with co-occurring mental health and substance use disorders. These staff members are multidisciplinary and represent addictions, mental health, corrections, and primary care agencies in Winnipeg. Since the implementation of the workshops, the vast majority of employees in all mental health and addictions services in the City of Winnipeg have received some common training in co-occurring disorders; there are more than 500 individual participants. Frontline clinicians are aware of a broader range of services that are available to their clients and report making more appropriate referrals and consulting more often. The number of complex cases being referred to the CODI leadership group for problem-solving interventions has been reduced as there is more and improved communication at the direct service levels. In conjunction with other activities, such as policy and practice guideline development, services have been modified for individuals and families with co-occurring disorders.

Geriatric Program Assessment Team

This team has received between 2,200 and 2,500 referrals, and geriatric assessments were completed on 72 to 75 per cent. Clients are then connected with resources such as day hospital, home care, and inpatient rehabilitation to stay in the community as long as possible. By maintaining clients in their home environment people can maintain their autonomy and it reduces overall costs to the health-care system.

Other strengths identified by Accreditation Canada include:

Revised Vision, Mission and Values Statement and Strategic Plan

"All these elements are now in place for the time frame 2011-2016. These documents constitute a major strength in that they clearly set out the direction for the organization for the next five years," the report said.

Personal care home priorities

The development of strategic priorities for the personal care home program over the next five years "give the program committee a valuable direction for progress," the report said.

Partnerships in health

"Open participatory relationships exist with multiple community partners that go beyond just the geographic to include faith-based and cultural communities," the report said. "There are several health promotion activities underway that reinforce partnerships, i.e., Winnipeg in Motion. They are responsive to communities through timely access and the program outreach such as the GPAT."

In addition to singling out leading practices, Accreditation Canada also offered up opportunities where the Region could improve.

For example, it noted that for each program reviewed the Region needs to improve the collection and reconciliation of medication information. Every personal care home needs a formal plan to reconcile medications at all transfer points. "Because of the large volume of respite admissions in some homes, the Region is encouraged to develop a process to ensure that medication is effectively reconciled at transfer and on discharge."

Accreditation Canada noted that while long-term care was a strength overall, the Region does face challenges in ensuring each of the 38 personal care homes operating in the community are operating from the same page when it comes to certain operational issues, especially those touching on safety.

"The strength of maintaining independent governance and cultural identity within these homes is somewhat offset by a variety of approaches to overall direction," said the report. "This begins to matter with varying approaches to safety as a written strategic priority among PCH's. PCH's, therefore, are encouraged to develop operational plans that acknowledge and reconcile plans with the overall strategic goals and objectives (of the Region) including the directions and priorities outlined for the PCH program."

The message is clear, said Réal Cloutier, Chief Operating Officer and Vice President of Long Term Care & Community Area Services for the Winnipeg Health Region. "Any one personal care home that does not meet accreditation requirements in a specific area standard area will impact on the compliance for the entire program. Therefore, we all need to work together towards meeting regional standards to ensure compliance around safety requirements and, ideally, our efforts should be directed towards exceeding those wherever possible."

About Accreditation Canada

Accreditation Canada is a not-for-profit, independent organization accredited by the International Society for Quality in Health Care (ISQua). It provides national and international health-care organizations with an external peer review process to assess and improve the services they provide to their patients and clients based on standards of excellence. Accreditation Canada's programs and guidance have helped organizations promote quality health care for over 50 years.

To learn more, visit

Why accreditation matters

The accreditation process is designed to ensure participating health-care facilities are providing the best care possible. The accreditation program enables organizations to use accreditation as a framework for quality and a roadmap for improvement. Each year, surveyors visit various regions, multi-site and single site organizations across the country to assess how care is delivered noting strengths and areas for improvement.

Programs deemed to be among the best in the country receive a leading practice designation. Those with serious deficiencies are given a yellow or red flags, meaning improvements must be made and a follow-up report filed. Surveyors may also highlight programs that are operating fairly well, but still require some enhancements to meet best practice standards. Each accreditation cycle takes about three years, with surveyors visiting once a year to conduct reviews of specific programs.

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