Baycrest receives top honour from Accreditation Canada

Accreditation Canada has awarded Baycrest Health Sciences Accreditation with Exemplary Standing for its quality, client outcomes and health system performance – the highest possible standing granted.  Baycrest is one of the few elite healthcare organizations in Canada to receive this prestigious designation.  Baycrest also received five Leading Practice awards, honouring practices that are innovative and creative, client and family-centred, evaluated, and the results of which are demonstrated, sustainable and adaptable.

ACSealAwESDuring a four-day on-site visit, Accreditation Canada surveyors evaluated more than 1,500 standards that address governance and leadership, infection prevention and control, and medication management. Baycrest met a remarkable 99.9 per cent of these criteria. In addition, the organization met all required organizational practices – essentials that focus on the safety and quality of healthcare delivery.  “The accreditation process allows us to assess every aspect of what we do against national standards,” says Carol Anderson, VP, Clinical Programs and Chief Nursing Officer. “This achievement reflects the commitment of our staff, who strive to achieve excellence and provide the very best care to seniors in our community every day.”

Surveyors praised Baycrest’s care on campus and in the community, as well as its focus on safety, the strength of its interdisciplinary care team model, and its commitment to contributing expertise in brain health and aging to the broader healthcare system. “We are thrilled that Accreditation Canada has recognized the extraordinary level of care within our programs and services,” says Dr. William Reichman, president and CEO of Baycrest. “In fact, no matter what area the surveyors visited, residents and patients shared just how much they love Baycrest – that sentiment alone is exemplary.”

View the 2015 Accreditation Report


Leading practices

Accreditation Canada defines a Leading Practice as an innovative and creative example of leadership and service delivery carried out by a health service organization To be approved, the practice must be: innovative and creative; client/family centred; evaluated and demonstrates its intended results; sustainable and adaptable.
Baycrest has received the following Leading Practice awards from Accreditation Canada

Building Capacity in Interprofessional Integration of Care: Behaviour Support Outreach Teams.

Baycrest was identified by the Toronto Central LHIN as the lead organization for the Behavioural Supports for Seniors Program (BSSP).  This program included implementation of a Transitional Behavioural Support Unit, an education consortium, and two outreach teams:

  • Long Term Care Behavioural Support Outreach Team (LTCBSOT): The primary role of the LTCBSOT is to provide support to 36 long term care homes in the TCLHIN.  Support includes a Registered Nurse-Personal Support Worker dyad working with staff in LTCHs to build capacity through modelling different approaches for care of residents exhibiting responsive behaviours. 
  • Community Behavioural Support Outreach Team (CBSOT): The CBSOT serves seniors living in the community. The team is embedded within the Toronto Central Community Care Access Centre and works closely with primary care and community support services.  Working collaboratively with the client, their informal and formal caregiver(s) and circle of care, the team works to manage challenging behaviours in the home environment.

Development of an Advance Care Planning Policy and Toolkit

Baycrest implemented a robust process for determining and documenting resident and clients wishes for life sustaining treatment. These effective and efficient solutions included the development of an ACP brochure, booklet titled Your Wishes Matter, and the Plan for Life Sustaining Treatment form to ensure that, whenever possible, future care and treatment decisions are made that respect the values and wishes of the client.

The Antimicrobial Stewardship Program

In mid-2012, Baycrest implemented a centre-wide Antimicrobial Stewardship Program (ASP), adapting key principles from literature in acute care, to suit the needs, capability and capacity of a long-term care setting.  The Baycrest ASP ensures the most appropriate use of antibiotics for Baycrest clients.  Along with improving and maintaining resistance, the program aims to improve client care and safety by reducing unnecessary antibiotic exposure, and therefore risks of the antibiotics themselves (e.g. risk of allergic reaction, side effects and Clostridium difficile diarrhea).

Seniors Support Volunteer Program

The Seniors Support Program provides support to seniors and family caregivers residing in the community through friendly visiting, utilizing technology including the telephone and electronic mail. In addition, a Skype service is also available. The friendly visiting service (Friendly Visits and ePals) is offered in over 10 languages (English, French, German, Hebrew, Hungarian, Italian, Portuguese, Russian, Spanish, Turkish, Yiddish) and is often the first connection to Baycrest for our clients and families. The Seniors Support Program is committed to ensuring that each client receives a contact every week. Delivered by a dedicated group of 27 volunteers, this free weekly program makes over 10,000 client contacts per year.

Enduring Consent to Influenza Vaccination

In chronic care and long-term care (LTC) facilities, patients and residents frequently go through multiple rounds of annual influenza immunization. As with any other medical intervention, immunization requires informed consent. In the past, this consent had to be re-obtained every year and had to always be in writing. Due to varying degrees of cognitive impairments in patients and residents at Baycrest, providing consent is often delegated to substitute decision makers (SDMs), who may not be readily available to sign a consent form. This is why immunization campaigns used to take months to complete, often leaving patients unimmunized and unprotected

To address the problem, Baycrest’s Infection Prevention and Control (IPAC) team led the development and implementation of enduring consent. Signed once (e.g. on admission), such consent maintains its validity for as long as the patient or resident remains in Baycrest care. In addition, a process was created for obtaining an enduring consent in a verbal format. This was important, as many SDMs unable to be physically present on-site could still be reached over the phone. Combined, these two improvements resolved the challenges associated with the annual consent.  Following this implementation, there were significant improvements including a reduction in the time required to attain target immunization rates from 12 to 5 weeks, with >80% of all patients immunized within 3 weeks. Immunization rates were well above 80%, 93% and 90% in the Hospital, Long-Term Care facility and Assisted Living Facility, respectively.