Accreditation

Accreditation

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 it reflects the dedication and commitment of Baycrest’s staff and physicians to provide 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. 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, infection prevention and control practices. (518 standards were 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 were 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 were 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. 

 

View the Accreditation Canada survey or debrief video. 

2022 Leading Practice awards

The Apotex Centre staff introduced a novel technology called Obie. This provides a meaningful and cognitively stimulating experience to residents by projecting virtual games onto a surface. They can then play using simple movements.  

Learn more at Health Standards Organization. 

2021 Leading Practice awards

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. 

Supporting the seamless transfer of patient care and data-driven decision-making through the introduction of a Meditech prompt for order indications. 

An interprofessional, person-centred approach to COVID-19 testing for early detection of asymptomatic cases among mental health inpatients. 

A novel discovery and current state needs assessment to examine patient education practices and the health literacy organizational culture at Baycrest. 

A virtual medical and behavioural support approach to treat patients with responsive behaviours in dementia in their own homes. 

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 to inspect high-touch surfaces for the 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. 

An innovative suite of specialized services to support older adults to access needed virtual care through the COVID-19 pandemic and beyond.