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Infection Prevention and ControlInfection Prevention and ControlIn Accreditation Canada’s Qmentum Program

September 2011In Accreditation Canada’s Qmentum Program

September 2011

© Accreditation Canada/Agrément Canada

BiographieBiographie

Lucie Tremblay, inf., M.Sc., Adm. A., CHE Directrice des Soins infirmiers et des Services cliniques, Centre gériatrique Maimonides Donald‐Berman. Jewish Eldercare Centre

Lucie Tremblay est directrice des soins infirmiers et services cliniques au Centre gériatrique Maimonides Donald‐Berman affilié à lʹuniversité McGill où elle détient un poste conjoint. Elle est conférencière invitée tant à lʹécole des soins infirmiers quʹàlʹécole du service social. Elle supervise les étudiants de cette université. Elle est aussi directrice des soins infirmiers et services spécialisés (intérim) au CHSLD juif de Montréal. Elle a, au cours de sa carrière, occupé différentes fonctions dans des établissements de soins de longue durée. Son implication auprès des personnes âgées lʹon amenée à publier un certain nombre dʹarticles et de faire plusieurs présentations sur des moyens pour améliorer la qualité de vie des personnes âgées vivant en institution. Elle a obtenu un DEC en soins infirmiers en 1984. Elle détient un Baccalauréat en sciences obtenu en 1988 et maîtrise en administration des services de santé obtenue en 1992. Elle détient le titre professionnel CHE obtenu en 2003 (Certified Health Executive) du Collège canadien des Leaders en Santé. En 2007, elle a obtenu le prix du ʺprofessionnel de lʹannéeʺ de lʹAssociation <Jewish Aging Services of North America>, en 2008 elle a obtenu le prix Florence pour l’excellence des soins de l’ordre des infirmières et infirmiers du Québec et en juin 2011 elle a obtenu le prix « Nursing Leadership Award » du Collège Canadien des Leaders en santé. Lucie Tremblay siège au comité de recherche du Centre gériatrique Maimonides, groupe affilié au réseau Solidage (McGill University‐Université de Montréal Research Group on Integrated Services for Older Persons).


Presentation OutlinePresentation Outline

Accreditation Canada’s Qmentum Program Infection Prevention and Control in Qmentum

Standards Required Organizational Practices Performance Measures

Results from Canadian Health Care Organizations


Accreditation CanadaAccreditation Canada

Major national accreditation body for organizations across all health sectors in Canada An independent, non-governmental, non-profit

organization Accredited by the International Society for Quality

in Healthcare - 2006

© Accreditation Canada/Agrément Canada 5

Accreditation Canada’s Qmentum ProgramAccreditation Canada’s Qmentum Program

In 2008, Accreditation Canada introduced a new accreditation program called Qmentum 3 year cycle, onsite visit by peer surveyors Involves examining everyday activities and services

against standards of excellence

SERVICE EXCELLENCECustomized as required for specific sectors, services,

and markets

STANDARDS AREAS

CLIENT EXPERIENCE

08/10

EFFECTIVE ORGANIZATION

SUSTAINABLE GOVERNANCE

TM

MC

POPULATIONS (used by regions)

• Cancer• Child/Youth • Chronic Conditions

• Maternal/Child • Mental Health • Public Health

SECTORS and SERVICES

• Acquired Brain Injury• Ambulatory Care• Assisted Reproductive Technology • Blood and Transfusion• Cancer Care and Oncology • Case Management• Child Welfare • Community Health• Critical Care • Developmental Disabilities • Diagnostic Imaging• Emergency Department• Emergency Medical Services• Home Care• Hospice Palliative and End of Life• Infection Prevention and Control

• Laboratory • Long Term Care• Managing Medications • Medicine• Mental Health • Obstetrics/Perinatal Care• Operating Rooms• Organ and Tissue Donation and Transplant• Point-of-Care Testing• Primary Care• Rehabilitation • Reprocessing and Sterilization• Staffing Agencies• Substance Abuse and Problem Gambling• Surgical Care• Telehealth

CUSTOM MARKETS

• Aboriginal Health Services• Corrections Canada

• Primary Health• Stroke

• Sterilization


Infection Prevention and Control StandardsInfection Prevention and Control Standards

Based on research and best practice information in the field, and national standards

Canadian Standards Association (CSA)

Public Health Agency of Canada (PHAC)

Community and Hospital Infection Control Association-Canada (CHICA-Canada)

Measures compliance against standards of excellence, Required Organizational Practices, and indicators


Infection Prevention and Control Standards (cont’d)Infection Prevention and Control Standards (cont’d)

Investing in infection prevention and control Monitoring trends in infections Establishing linkages with other organizations and the community Using research, evidence, and best practice information Maintaining infection prevention and control policies and

procedures Keeping people safe from infections

Educating staff, clients and families Implementing a comprehensive hand hygiene strategy Preventing contamination of food, linen, equipment, devices, and

supplies Identifying, managing, and controlling infections


Infection Prevention and Control Standards (cont’d)Infection Prevention and Control Standards (cont’d)

Providing a safe and suitable environment

Cleaning and disinfecting the physical environment Following manufacturers’ recommendations and accepted standards

of practice to clean and reprocess reusable medical devices Being prepared for outbreaks and pandemics

Implementing a coordinated approach to identify and manage outbreaks and respond to pandemics


Required Organizational PracticesRequired Organizational Practices


Required Organizational Practices (cont’d)Required Organizational Practices (cont’d)

List of Required Organizational Practices (ROPs) in the area of infection prevention and control Hand hygiene education and training Hand hygiene audit Infection control guidelines Infection rates Influenza vaccine Pneumococcal vaccine Sterilization processes


Performance MeasuresPerformance Measures

Organizations collect infection control indicators to aid in their quality improvement initiatives Health Care Associated Infection MRSA infection rate C. difficile infection rate

Surgical Site Infection Post surgical infections rate Timely administration of prophylactic antibiotic rate


Results from Canadian Health Care OrganizationsResults from Canadian Health Care Organizations

Required Organizational Practice 2008 Met (%)

2009Met (%)

Hand hygiene education and training 94 97

Hand hygiene audit n/a 72

Infection control guidelines 91 97

Infection rates 63 76

Influenza vaccine 86 92

Pneumococcal vaccine 93 91

Sterilization processes 88 87


Results from Canadian Health Care Organizations (cont’d)Results from Canadian Health Care Organizations (cont’d)

Strengths Implementing policies and procedures in line with

international, federal, and provincial/territorial infection control guidelines

Providing access to alcohol-based hand rubs at the point-of-care and service delivery

Delivering hand hygiene education and training Opportunities for Improvement

Monitoring compliance with hand hygiene practices and using the results to make improvements


Next StepsNext Steps

Continuing to enhance Qmentum standards, ROPsand performance measures in the area of patient safety Continuing to share results with partners and

stakeholders across Canada to improve the safety and quality of health care services for patients and their families

Accreditation Canada1150 Cyrville Road,

Ottawa, ON K1J 7S9 ,

Accreditation Canada1150 Cyrville Road,

Ottawa, ON K1J 7S9 ,

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