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Baycrest Completes Successful Accreditation Canada Survey

Effective December 2022, Baycrest has been accredited with Exemplary Standing. This is the highest level of performance achievable in the Accreditation Canada program, which is used by over 10,000 sites in 30 countries.  This is an important milestone to celebrate and reflects the dedication and commitment of Baycrest’s staff and physicians to providing safe, high-quality, client- and family-centred care.

How was Baycrest assessed?

Baycrest has transitioned to a sequential survey model for Accreditation. The sequential survey is a new approach offered by Accreditation Canada to better support organizations to engage in continuous quality improvement. In order to achieve Exemplary Standing, Baycrest’s practices were assessed by multiple surveyors during three separate site visits.

  • In January 2021, we completed the first segment of our survey, which focused on ambulatory and mental health services, as well as corporate evaluations of medication management and infection prevention and control practices (518 standards assessed).
  • In November 2021, we completed the next phase of our sequential survey, which focused on governance, leadership, and inpatient hospital service excellence standards (491 standards assessed).
  • In November 2022, we completed the third and final segment of our full survey, which focused on the Apotex Centre, Jewish Home for the Aged (398 standards assessed). 

Accreditation decisions are based on compliance with standards.  Across all three site visits, Baycrest met 1,406 out of 1,407 applicable standards, including all required organizational practices.  In addition to meeting all but one standard, the surveyors recognized the passion and engagement of Baycrest’s staff and physicians. 

Baycrest’s accreditation award is an incredible achievement that would not be possible without the day-to-day  commitment of Baycrest’s staff, physicians, resident / client and family partners, learners, and volunteers.   


2022 Leading Practice Awards

2021 Leading Practice Awards

  • Application of an Ethics framework during COVID-19, Visitation Appeals
    In order to maintain the health and safety of patients, residents, staff, and physicians during the COVID-19 pandemic, visitor restrictions and policies were introduced at Baycrest in March 2020. Policy changes impacted visitor access in the hospital, the long-term care home, and the retirement home. With restrictions fluctuating depending on the COVID-19 situation in the organization and the local community, it was important to establish a principle- and value-based process to consider visitation appeals.

    Prior to the introduction of a formal appeals process, requests for visitor exceptions were managed within business lines (e.g., the hospital or the long-term care home) which had the potential to: i) compromise the therapeutic relationship between the care team and client and family; and, ii) result in inconsistent processes and outcomes for patients and families.

    The keys to establishing a successful appeals process were threefold:
    • Structured decision-making consistently guided by established ethics principles and values.
    • An Appeals Committee comprised of individuals with varied perspectives, including two client and family partners, the Director of Clinical Ethics, and the Client Relations & Experience Officer.
    • Ad hoc consultation with operational leaders and subject matter experts (e.g., Infection Prevention and Control) as appropriate stakeholders to the case under deliberation.

    The appeals committee meets on an ad hoc basis in response to visitor or client appeals with the expectation that decisions are communicated within three business days of appeal submission.
  • Antimicrobial stewardship program: indication prompt for antimicrobial orders
    Supporting the seamless transfer of patient care and data-driven decision-making through the introduction of a Meditech prompt for order indications.
  • COVID-19 surveillance testing for patients with responsive behaviours
    An interprofessional, person-centred approach to COVID-19 testing for early detection of asymptomatic cases among mental health inpatients.
  • Enabling patient and family engagement in care: establishing the design and development of a new Patient, Family and Consumer Education Program using a de novo needs assessment process
    A novel discovery and current state needs assessment to examine patient education practices and the health literacy organizational culture at Baycrest.
  • Responsive behaviours in dementia: novel virtual behavioural support model during COVID-19
    A virtual medical and behavioural support approach to treat patients with responsive behaviours in dementia in their own homes.
  • Transition of Ownership - Environmental Services Team, Glo Germ Audits and Performance Huddles
    At Baycrest, we are committed to providing a clean and well-maintained space for our patients, families, staff and physicians. Glo GermTM cleaning audits are one of the common methods used by Environmental Services (EVS) departments to monitor and improve hospital cleanliness. Audits use Glo Germ gel or lotion, invisible under regular light, to mark high-touch areas in patient rooms and washrooms prior to cleaning by housekeeping staff. After cleaning, EVS supervisors using an ultraviolet (UV) flashlight inspect high-touch surfaces for presence of gel that glows under the UV light.

    Since the fall of 2020, the EVS department has formally embedded Glo Germ audit reviews as a standing agenda item into EVS team performance huddles. Notably, after thorough consultations and training by Quality Improvement specialists, the responsibility of leading these reviews has been transitioned to EVS staff. At the monthly huddles attended by housekeeping staff, supervisors and managers, staff review measures that they have selected for their performance board. The board acts as a visual tool to monitor team performance and identify improvement opportunities.
  • Virtual specialized geriatric services
    An innovative suite of specialized services to support older adults to access needed virtual care through the COVID-19 pandemic and beyond.

2015 Leading Practice Awards

  • 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.

  • Integrated Community Care Team
    In response to the growing challenges in meeting the health care needs of frail, medically complex seniors, the difficulties in timely access to primary care, community care and specialty care, and the health care system’s priority to reduce unnecessary Emergency Department utilization by promoting the integration of geriatric care, a unique and innovative Integrated Community Care Team (ICCT) outreach model was developed, implemented and evaluated.

    The Integrated Community Care Team supports home-bound frail older adults in their homes and consists of three arms including primary care, shared care, and consultation. The ICCT model fosters integration at the point of care  by connecting patients and their primary care physicians to a dedicated, interprofessional team of primary and specialty care providers, community services including intensive case management, and specialty care resources