Canadian Accreditation Tools

Tracer Tool
Adapted from Canadian Accreditation Tool
INSTRUCTIONS: Work on a copy of this template.

- Select Score from the dropdown list.
- Press "Delete" to erase a selection.
- RE-SAVE FILE after making selections
OVERALL RESULTS
# of items met: 0
# of items not met: 0
STRENGTHS
AREAS FOR IMPROVEMENT
FUNCTIONING AS AN EFFECTIVE GOVERNING BODY

1.0, The roles, responsibilities, and legal obligations of the governing body are
defined and followed.
1.1 The roles, responsibilities, and legal obligations of the governing body are defined and regularly reviewed.
1.2 There is written documentation that identifies the governing body's roles and responsibilities, as well as how those roles and
responsibilities are carried out.
1.3 The governing body approves, adopts, and follows the ethics framework used by the organization.
1.4 The governing body adopts a code of ethical conduct for its members.
1.5 There is a process to develop the governing body's by-laws and policies and update them regularly.
1.6 The governing body's by-laws and policies are consistent with its mandate, roles, responsibilities, accountabilities, and the organization's
ethics framework.
2.0 The governing body has the appropriate membership to fulfill its role.
2.1 The mix of background, experience, and competencies needed in the governing body's membership is identified.
2.2 There are established mechanisms for the governing body to hear from and incorporate the voice and opinion of clients and families.
2.3 The governing body includes clients as members, where possible.

2.4 There is a documented process that is followed to elect or appoint the chair of the governing body.
2.5 The roles and responsibilities of the chair are described in a position profile, terms of reference, or by-laws.
2.6 There are written criteria and a defined process for recruiting and selecting new members of the governing body.
2.7 New members of the governing body receive an orientation before attending their first meeting.
2.8 Each member of the governing body signs a statement acknowledging his or her role and responsibilities, including expectations of the
position and legal duties.
2.9 Members of the governing body receive ongoing education to help them fulfill their individual roles and responsibilities and those of the
governing body as a whole.
2.10 The governing body's membership policies and/or by-laws address term lengths and limits, attendance requirements, and
compensation.
2.11 The governing body's renewal cycle supports the addition of new members while maintaining a balance of experienced members to
support the continuity of corporate memory and decision-making.
3.0 There is a defined and formal process for decision making.

3.1 The ethics framework and evidence-informed criteria are used by the governing body to guide decision making.
3.2 Areas where decision making is shared with government, funding authorities, and other health organizations are identified.
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3.3 The information required to support decision making is available and accessible to the governing body.
3.4 The governing body has processes in place to oversee the functions of audit and finance, quality and safety, and talent management.
3.5 Required information and documentation is received in enough time to prepare for meetings and decision making.
3.6 The governing body reviews the type of information it receives to assess its appropriateness in helping the governing body to carry out its
role.
DEVELOPING A CLEAR DIRECTION FOR THE ORGANIZATION

4.0, The governing body works with the organization's leaders to develop the
organization's mission statement.
4.1 The governing body works in collaboration with the organization's leaders to develop the organization's mission statement.
4.2 When developing or updating the mission statement, input is sought from team members and external stakeholders, including clients,
families, and partners.
4.3 Government or the organization's shareholders are regularly consulted to confirm the appropriateness of the organization's mandate and
core services and to develop a common understanding about performance expectations.
4.4 The organization's mission statement is regularly reviewed and revised as necessary to reflect changes in the environment, scope of
services, or mandate.
5.0 The governing body defines and models the organizational values.
5.1 The governing body works with the organization's leaders to define or update the organization's values statement.
5.2 The governing body collaborates with the organization's leaders to seek input from team members, clients, and families to define or
update the organization's values statement.
5.3 The governing body provides oversight of the organization's efforts to build meaningful partnerships with clients and families.
5.4 The governing body monitors and evaluates the organization's initiatives to build and maintain a culture of client- and family-centred care.
5.5 The governing body has a formal process to understand, identify, declare, and resolve conflicts of interest.
6.0 organization's vision and set the strategic plan, goals, and objectives.
6.1 The governing body oversees the strategic planning process and provides guidance to the organization's leaders as they develop and
update the organization's vision and strategic plan.
6.2 The governing body, in consultation with the organization's leaders, identifies timeframes and responsibility for achieving the strategic
goals and objectives.
6.3 The governing body works with the organization's leaders to conduct an ongoing environmental scan to identify changes and new
challenges, and ensures that the strategic plan, goals, and objectives are adjusted accordingly.
SUPPORTING THE ORGANIZATION TO ACHIEVE ITS MANDATE

7.0, The governing body recruits, selects, supports, and evaluates the CEO and
ensures an organizational talent management plan is in place.
7.1 The governing body oversees the recruitment and selection of the CEO.The governing body oversees the recruitment and selection of the
CEO.
7.2 The governing body follows a policy on CEO compensation.

7.3 The governing body develops and updates the position profile for the CEO.
7.4 In partnership with the CEO, the governing body sets performance objectives for the CEO and reviews them annually.
7.5 The governing body supports and commits resources to the ongoing professional development of the CEO.
7.8 The governing body has a succession plan for the CEO.
7.9 The governing body oversees the development of the organization's talent management plan.
8.0, The governing body oversees a process for granting and renewing privileges to health care
providers.
8.1 A documented process is followed for granting privileges.

8.2 A documented process is followed to review and evaluate the performance of health care professionals who have been granted privileges.
8.3 A documented process is followed for reviewing and renewing privileges (including processes for addition of new privileges or alteration of
privileges) on a regular basis.
8.4 There is a documented process to address any performance issues identified with health care professionals with privileges.
8.5 The governing body verifies that documented processes for appeals of decisions regarding privileges are followed.
9.0, The governing body has an effective system of financial planning and control
which supports achievement of the strategic goals and objectives.
9.1 The governing body approves the organization's capital and operating budgets.
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9.2 The governing body ensures the integrity of the organization's financial statements, internal controls, and financial information systems.
9.3 The governing body reviews the organization's financial performance in the context of the strategic plan and key performance areas such
as utilization, risk, and safety.
9.4 The governing body reviews and approves the organization's capital investments and major equipment purchases.
9.5 The governing body oversees the organization's resource allocation decisions as part of its regular planning cycle.
9.6 When reviewing and approving resource allocation decisions, the governing body assesses the risks and benefits to the organization.
9.7 When approving resource allocation decisions, the governing body evaluates the impact of the decision on quality, safety and client
experience.
9.8 The governing body anticipates the organization's financial needs and potential risks, and develops contingency plans to address them.
9.9 The governing body addresses recommendations in financial reports and from the CEO and the organization's leaders.
10.0, The governing body fosters and supports a culture of patient safety throughout
the organization.
10.1 The governing body adopts patient safety as a written strategic priority for the organization.
10.2 The governing body monitors organization-level measures of patient safety.
10.3 The governing body addresses recommendations made in the organization's quarterly patient safety reports.
10.4 The governing body regularly reviews the frequency and severity of safety incidents and uses this information to understand trends,
client and team safety issues in the organization, and opportunities for improvement.
10.5 The governing body regularly hears about quality and safety incidents from the clients and families that experience them.
BEING ACCOUNTABLE AND ACHIEVING SUSTAINABLE RESULTS

11.0, The governing body strengthens relationships with stakeholders and the
community.
11.1 The governing body works with the CEO to identify stakeholders and learn about their characteristics, priorities, interests, activities, and
potential to influence the organization.
11.2 In consultation with the CEO, the governing body anticipates, assesses, and responds to stakeholders' interests and needs.
11.3 The governing body works with the CEO to establish, implement, and evaluate a communication plan for the organization.
11.4 The communication plan includes strategies to communicate key messages to clients and families, team members, stakeholders, and
the community.
11.5 The governing body promotes the organization and demonstrates the value of its services to stakeholders and the community.
11.6 The governing body regularly consults with and encourages feedback from stakeholders and the community about the organization and
its services.
11.7 The governing body, in collaboration with the organization's leaders, share reports about the organization's performance and quality of
services with teams, clients, families, the community served, and other stakeholders.
12.0, The governing body works with the CEO to reduce risks to the organization and
promote ongoing quality improvement.
12.1 REQUIRED ORGANIZATIONAL PRACTICE: The governing body demonstrates accountability for the quality of care provided by the
organization.
12.1.1 The governing body is knowledgeable about quality and safety principles, by recruiting members with this knowledge or providing
access to education.
12.1.2 Quality is a standing agenda item at all regular meetings of the governing body.
12.1.3 The key system-level indicators that will be used to monitor the quality performance of the organization are identified.
12.1.4 At least quarterly, the quality performance of the organization is monitored and evaluated against agreed-upon goals and objectives.
12.1.5 Information about the quality performance of the organization is used to make resource allocation decisions and set priorities and
expectations.
12.1.6 As part of their performance evaluation, senior leaders who report to the governing body (e.g., the CEO, Executive Director, Chief of
Staff) are held accountable for the quality performance of the organization.
12.2 The governing body works with the CEO and the organization's leaders to develop an integrated quality improvement plan.
12.3 The governing body ensures that an integrated risk management approach and contingency plans are in place.
12.4 The governing body receives summary reports of client and family complaints received by the organization.
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12.5 The governing body monitors and provides input into the organization's strategies to address client flow and variations in service
demands.
12.6 The governing body promotes learning from results, making decisions that are informed by research and evidence, and ongoing quality
improvement for the organization and the governing body.
12.7 The governing body demonstrates a commitment to recognizing team members for their quality improvement work.
13.0, The governing body regularly evaluates the performance of individual board
members and its performance as a whole.
13.1 The governing body publicly discloses information about its governance processes, decision-making, and performance.
13.2 The governing body's activities and decisions are recorded and archived.
13.3 The governing body shares the records of its activities and decisions with the organization.
13.4 The governing body follows a process to regularly evaluate its performance and effectiveness.
13.5 The governing body conducts or participates in an assessment of its structure, including size and committee structure.
13.6 The governing body regularly evaluates the performance of the board chair based on established criteria.
13.7 The governing body regularly reviews the contribution of individual members and provides feedback to them.
13.8 ACCREDITATION CANADA REQUIRED INSTRUMENT: The governing body regularly assesses its own functioning using the
Governance Functioning Tool.
13.9 The governing body prepares an annual report of its achievements.
13.10 The governing body identifies and addresses opportunities for improvement in how it functions.
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Unit:
Dept.: Quality Department
Date:
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Team:
# of items completed: 0
% of applicable questions scored MET: #DIV/0!
Score Findings/Recommendations
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OVERALL RESULTS
# of items met:
# of items not met:
STRENGTHS
Infection Prevention and Control Standards

PLANNING AND DEVELOPING THE IPC PROGRAM
1.0, The Infection Prevention and Control (IPC) program is planned and developed
based
1.2 onand
Evidence organizational priorities,
best practices in IPC are reviewedevidence,
when planningand best practices.
and developing the IPC program.
1.3 The resources needed to support the IPC program are regularly reviewed.
2.0 A collaborative approach is used to support the IPC program.
2.1 There is an IPC team responsible for planning, developing, implementing and evaluating the IPC program.
2.2 There are one or more qualified IPC professionals as part of the IPC team.
2.3 There is access to a qualified IPC physician to provide input to the IPC team.
2.4 There is an interdisciplinary committee to provide guidance about the IPC program.
2.5 The interdisciplinary committee regularly evaluates the program's structure and functions and makes improvements as needed.
2.6 The IPC team is consulted when planning and designing the physical environment, including planning for construction and renovations.
2.7 Input is gathered from the IPC, and the OHS teams to maintain optimal environmental conditions within the organization.
2.8 Environmental services and the IPC team are involved in maintaining processes for laundry services and waste management.
2.9 Input is gathered from the IPC team to maintain processes for selecting and handling medical devices/equipment.
2.10 Applicable standards for food safety are followed to prevent food-borne illnesses.
2.11 Input is gathered from the IPC team when planning for pandemics at the organizational level.
3.0 The organization collaborates with partners to promote IPC.

3.1 The organization partners with organizations across the continuum of care to implement IPC activities.
3.2 Trends in health care-associated infections and significant findings are shared with other organizations, public health agencies, clients and families, and
the community.
IMPLEMENTING THE IPC PROGRAM

4.0, IPC policies and procedures are maintained based on applicable regulations,
evidence and best practices, and organizational priorities.
4.1 A risk assessment is completed to identify high-risk activities, and the activities are addressed in policies and procedures.
4.2 There are policies and procedures that are in line with applicable regulations, evidence and best practices, and organizational priorities.
4.3 There are policies and procedures for using aseptic techniques when preparing, handling, and administering sterile substances both within the
preparation area and at the point of care.
4.4 There are policies and procedures for loaned, shared, consigned, and leased medical devices.
4.5 Team members and volunteers are provided with access to IPC policies and procedures.
4.6 Compliance with IPC policies and procedures is monitored and improvements are made to the policies and procedures based on the results.
4.7 IPC policies and procedures are updated regularly based on changes to applicable regulations, evidence, and best practices.
5.0, Team members, clients, families, and volunteers are engaged in promoting an
IPC culture within the organization.
5.1 A multi-faceted approach to promoting IPC is used within the organization.
5.2 Team members, clients and families, and volunteers are engaged when developing the multi-faceted approach for IPC.
5.3 The multi-faceted approach to IPC includes an education program tailored to IPC priorities, services, and client populations.
5.4 Information on how to safely perform high-risk activities is provided, including appropriately using PPE as outlined in its policies and procedures.
5.5 Team members and volunteers are required to attend the IPC education program at orientation and on a regular basis based on their IPC roles and
responsibilities.
5.6 The effectiveness of the multi-faceted approach for promoting IPC is evaluated regularly and improvements are made as needed.
6.0 Clients, families, and visitors are engaged in IPC practices.

6.1 Clients, families, and visitors are provided with information about routine practices and additional precautions as appropriate, and in a format that is easy
to understand.
6.2 Client, families, and visitors are provided with access to hand hygiene resources and PPE based on the risk of transmitting microorganisms.
6.3 Clients are screened to determine whether additional precautions are required based on the risk of infection.
7.0 The OHS program addresses organizational priorities for IPC.

7.1 There are OHS policies and procedures to reduce the risk of transmitting microorganisms among team members, and clients.
7.2 An immunization policy is developed or adopted to screen and offer vaccinations to team members.
7.3 There are policies and procedures for using PPE that are appropriate to the task.
7.4 There are work restrictions that are in line with OHS guidelines for team members, and volunteers with transmissible infections.
7.5 Policies, procedures, and legal requirements are followed when handling bio-hazardous materials.
7.6 There are policies and procedures for disposing of sharps at the point of use in appropriate puncture-, spill-, and tamper-resistant sharps containers.
7.7 Safety engineered devices for sharps are used.
8.0 A comprehensive hand-hygiene strategy is in place.

8.1 REQUIRED ORGANIZATIONAL PRACTICE: Hand-hygiene education is provided to team members and volunteers.
8.1.1 Team members and volunteers are provided with education about the hand-hygiene protocol.
8.2 There is a process to select and review products for hand hygiene, including alcohol-based hand rubs and hand soaps.
8.3 Team members, client, families, and volunteers have access to alcohol-based hand
rubs at the point of care.
8.4 Team members, and volunteers have access to dedicated hand-washing sinks.
8.5 Reminders are posted about the proper techniques for hand-washing and using alcohol-based hand rubs.
8.6 REQUIRED ORGANIZATIONAL PRACTICE: Compliance with accepted hand-hygiene practices is measured.
8.6.1 Compliance with accepted hand-hygiene practices is measured using direct observation (audit). For organizations that provide services in clients'
homes, a combination of two or more alternative methods may be used, for example: • Team members recording
their own compliance with accepted hand-hygiene practices (self-audit). • Measuring product use.
• Questions on client
satisfaction surveys that ask about team members' hand-hygiene compliance. • Measuring the quality of
hand-hygiene techniques (e.g., through the use of ultraviolet gels or lotions).
8.6.2 Hand-hygiene compliance results are shared with team members and volunteers.
8.6.3 Hand-hygiene compliance results are used to make improvements to hand-hygiene practices.
9.0 A clean and disinfected physical environment is maintained.

9.1 The areas in the physical environment are categorized based on the risk of infection to determine the necessary frequency of cleaning, the level of
disinfection, and the number of environmental services team members required.
9.2 Roles and responsibilities are assigned for cleaning and disinfecting the physical
environment.
9.3 There are policies and procedures for cleaning and disinfecting the physical environment and documenting this information.
9.4 There are policies and procedures for cleaning and disinfecting the rooms of clients who are on additional precautions.
9.5 Compliance with policies and procedures for cleaning and disinfecting the physical environment is regularly evaluated, with input from clients and
families, and improvements are made as needed.
9.6 When cleaning services are contracted to external providers, a contract is established and maintained with each provider that requires consistent levels
of quality and adherence to accepted standards of practice.
9.7 When cleaning services are contracted to external providers, the quality of the services provided is regularly monitored.
10.0, Manufacturers' instructions and accepted standards of practice are followed

when cleaning, disinfecting, and sterilizing reusable medical devices andequipment.
10.1 Clear and concise policies and procedures are developed and maintained for cleaning, disinfecting, and sterilizing reusable medical devices and
equipment.
10.2 If neurosurgical services are provided, there are policies and procedures to prevent the transmission of Creutzfeldt-Jakob Disease (CJD).
10.3 Required training, education, and experience are defined for all team members that participate in cleaning, disinfecting, and/or sterilizing medical
devices and equipment.
10.4 Current manufacturers' instructions are upheld when cleaning, disinfecting, or sterilizing medical devices and equipment.
10.5 Policies, SOPs and manufacturers' instructions are accessible to all team members.
10.6 Cleaning, disinfection, and sterilization of critical and semi-critical single-use devices (SUD) is not permitted on-site, in line with the organization's policy
and regional regulations.
10.7 If cleaning, disinfection, or sterilization of reusable medical devices and equipment is contracted to external providers, a written agreement or contract
is maintained with each provider that outlines requirements and respective roles and responsibilities.
10.8 When cleaning, disinfection, or sterilization of reusable medical devices and equipment is contracted to external providers, the organization regularly
monitors the quality of the services provided.
10.9 When, cleaning, disinfection, and/or sterilization of medical devices or equipment is done in-house, team members involved in these processes are
provided with education and training in how to do so when they are first employed and on an ongoing
basis.
10.10 When an organization cleans, disinfects, and/or sterilizes devices and equipment in-house, there are designated and appropriate area(s) where these
activities are done.
10.11 The area where cleaning, disinfection, and/or sterilization of medical devices and equipment are done is equipped with hand hygiene facilities.
10.12 Eating and drinking, food storage, cosmetics application, and the contact lens handling are all prohibited in the area where cleaning, disinfection,
and/or sterilization of medical devices and equipment are done.
10.13 Items that require cleaning, disinfection, and/or sterilization are safely contained and transported to the appropriate area(s).
10.14 Appropriate Personal Protective Equipment (PPE) is worn when cleaning, disinfecting, or sterilizing medical devices and equipment.
10.15 Contaminated devices and equipment are cleaned before disinfection or sterilization is done.
10.16 Detergents, solutions, sterilants and disinfectants selected are in line with manufacturers' instructions, and are compatible with the devices being
cleaned, disinfected, or sterilized, and the equipment and processes for cleaning, disinfection or sterilization.
10.17 For each detergent, solution, sterilant, and disinfectant, manufacturers' instructions for use are followed.
10.18 Each device or set of devices are prepared for sterilization according to manufacturers' instructions.
10.19 An internal chemical indicator is placed in each package or container, according to the organization's quality control processes, to verify
that sterilizer penetration has occurred.
10.20 Sterilized packages are clearly identifiable and distinguished from non-sterilized items.
10.21 The integrity of each sterile package is maintained.
10.22 There is a process that allows for the tracking of medical devices associated with a sterilizer or sterilization cycle.
10.23 REQUIRED ORGANIZATIONAL PRACTICE: Processes for cleaning, disinfecting, and sterilizing medical devices and equipment are
monitored and improvements are made when needed.
10.23.1 There is evidence that processes and systems for cleaning, disinfection, and sterilization are effective.
10.23.2 Action has been taken to examine and improve processes for cleaning, disinfection, and sterilization where indicated.
11.0, Specific requirements are followed to reprocess flexible endoscopic devices.[Note: The following
criteria are additional requirements that apply specifically to reprocessing flexible endoscopes. Rigid
endoscopes are almost exclusivelycritical devices requiring sterilization, and are addressed by the other
standardsin this document.
11.1 Team members are trained on the policies and procedures for reprocessing flexible endoscopes.
11.2 Areas for reprocessing flexible endoscopes are physically separate from client care areas.
11.3 Endoscope reprocessing areas are equipped with separate cleaning and decontamination work areas as well as storage, dedicated
plumbing and drains, and proper air ventilation.
11.4 Manufacturers' instructions are followed to pre-clean flexible endoscopes immediately at point of use.
11.5 Before cleaning, the flexible endoscope is checked for internal and external damage, and if repair is required, the endoscope is prepared
and packaged for shipping in accordance with manufacturers' instructions.
11.6 Before beginning high-level disinfection, each flexible endoscope is cleaned, rinsed, and dried according to the manufacturer's instructions.
11.7 Before beginning high level disinfection, immersible endoscopic components are soaked and manually cleaned using water and an
approved cleaning agent.
11.8 Flexible endoscopes are stored in a manner that minimizes contamination and damage.
11.9 A permanent record is maintained of the reprocessing history for each flexible endoscope.
11.10 The record of endoscopic device reprocessing includes the identification number and the type of endoscope, the identification number of
the automated endoscope reprocessor (if applicable), the date and time of reprocessing, the name or unique identifier of the client, the results of
the individual inspection and leak test, and the name of the person reprocessing the endoscope.
11.11 Preventive and scheduled maintenance, including repairs, is completed and documented for each automated endoscope reprocessor.
EVALUATING THE IMPACT OF THE IPC PROGRAM

12.0 A surveillance plan is in place to monitor health care-associated infections.
12.1 There is a surveillance plan that is in line with applicable regulations, evidence and best practices, and organizational priorities.
12.2 REQUIRED ORGANIZATIONAL PRACTICE: Health care-associated infections are tracked, information is analyzed to identify outbreaks
and trends, and this information is shared throughout the organization. NOTE: This ROP only applies to organizations
that have beds and provide nursing care.
12.3 There is a process to promptly detect suspected health care-associated infections in the organization.
12.4 There is access to a microbiology laboratory that offers expertise to the organization about identifying health care-associated infections.
12.5 Those responsible for receiving and responding to information about suspected health care-associated infections are identified.
12.6 The source or cause of health care-associated infections is investigated.
12.7 There are policies and procedures to contain and prevent the transmission of microorganisms by applying routine practices to all clients and
additional precautions as necessary.
12.8 IPC or public health experts are consulted with to control health care-associated infections, and the necessary information is reported to the
appropriate authorities in line with the applicable regulations.
12.9 Standard definitions and accepted statistical techniques are used to share and compare information about health care-associated infections.
12.10 The results of investigations are used to improve programs, policies, or procedures, and to prevent health care-associated infections from
recurring.
13.0 There is a coordinated approach for responding to outbreaks.

13.1 There are policies and procedures for identifying and responding to outbreaks in line with applicable regulations.
13.2 Team members and volunteers are provided with access to policies and procedures for identifying and managing outbreaks.
13.3 The organization collaborates with its partners, such as public health agencies, to define outbreaks in terms of person, place, and time.
13.4 Policies and procedures address how to manage emerging, rare, or problematic organisms, including antibiotic-resistant organisms.
13.5 There are policies and procedures about the roles and responsibilities of team members, and volunteers who are involved in identifying and
managing outbreaks.
13.6 Information is communicated about outbreaks to clients, families, team members, partners, other organizations, and the community when
appropriate.
13.7 Policies and procedures are regularly reviewed and improvements are made as needed following each outbreak.
14.0 Ongoing improvements to the IPC Program are made.

14.1 There is a quality improvement plan for the IPC program.
14.2 IPC performance measures are monitored.
14.3 Input is gathered from team members, volunteers, and clients and families on components of the IPC program.
14.4 The information collected about the IPC program is used to identify successes and opportunities for improvement, and to make
improvements in a timely way.
14.5 Results of evaluations are shared with team members, volunteers, clients, and families.
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DEVELOPING THE IPC PROGRAM
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mittee regularly evaluates the program's structure and functions and makes improvements as needed.
when planning and designing the physical environment, including planning for construction and renovations.
IPC, and the OHS teams to maintain optimal environmental conditions within the organization.
d the IPC team are involved in maintaining processes for laundry services and waste management.
IPC team to maintain processes for selecting and handling medical devices/equipment.
food safety are followed to prevent food-borne illnesses.
e IPC team when planning for pandemics at the organizational level.
collaborates with partners to promote IPC.

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E IPC PROGRAM
es are maintained based on applicable regulations,
nd organizational priorities.
eted to identify high-risk activities, and the activities are addressed in policies and procedures.
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and visitors are engaged in IPC practices.

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termine whether additional precautions are required based on the risk of infection.
m addresses organizational priorities for IPC.

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for sharps are used.
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cedures for cleaning and disinfecting the rooms of clients who are on additional precautions.
nd procedures for cleaning and disinfecting the physical environment is regularly evaluated, with input from clients and
re made as needed.
e contracted to external providers, a contract is established and maintained with each provider that requires consistent levels
ccepted standards of practice.
e contracted to external providers, the quality of the services provided is regularly monitored.
instructions and accepted standards of practice are followed

fecting, and sterilizing reusable medical devices andequipment.
s and procedures are developed and maintained for cleaning, disinfecting, and sterilizing reusable medical devices and
are provided, there are policies and procedures to prevent the transmission of Creutzfeldt-Jakob Disease (CJD).
tion, and experience are defined for all team members that participate in cleaning, disinfecting, and/or sterilizing medical
nstructions are upheld when cleaning, disinfecting, or sterilizing medical devices and equipment.
acturers' instructions are accessible to all team members.
d sterilization of critical and semi-critical single-use devices (SUD) is not permitted on-site, in line with the organization's policy
or sterilization of reusable medical devices and equipment is contracted to external providers, a written agreement or contract
der that outlines requirements and respective roles and responsibilities.
on, or sterilization of reusable medical devices and equipment is contracted to external providers, the organization regularly
rvices provided.
tion, and/or sterilization of medical devices or equipment is done in-house, team members involved in these processes are
raining in how to do so when they are first employed and on an ongoing
leans, disinfects, and/or sterilizes devices and equipment in-house, there are designated and appropriate area(s) where these
g, disinfection, and/or sterilization of medical devices and equipment are done is equipped with hand hygiene facilities.
d storage, cosmetics application, and the contact lens handling are all prohibited in the area where cleaning, disinfection,
devices and equipment are done.
ing, disinfection, and/or sterilization are safely contained and transported to the appropriate area(s).
otective Equipment (PPE) is worn when cleaning, disinfecting, or sterilizing medical devices and equipment.
s and equipment are cleaned before disinfection or sterilization is done.
terilants and disinfectants selected are in line with manufacturers' instructions, and are compatible with the devices being
zed, and the equipment and processes for cleaning, disinfection or sterilization.
olution, sterilant, and disinfectant, manufacturers' instructions for use are followed.
devices are prepared for sterilization according to manufacturers' instructions.
ndicator is placed in each package or container, according to the organization's quality control processes, to verify
s occurred.
re clearly identifiable and distinguished from non-sterilized items.
sterile package is maintained.
at allows for the tracking of medical devices associated with a sterilizer or sterilization cycle.
ZATIONAL PRACTICE: Processes for cleaning, disinfecting, and sterilizing medical devices and equipment are
ts are made when needed.
hat processes and systems for cleaning, disinfection, and sterilization are effective.
en to examine and improve processes for cleaning, disinfection, and sterilization where indicated.
ements are followed to reprocess flexible endoscopic devices.[Note: The following
al requirements that apply specifically to reprocessing flexible endoscopes. Rigid
ost exclusivelycritical devices requiring sterilization, and are addressed by the other
ument.
ained on the policies and procedures for reprocessing flexible endoscopes.
flexible endoscopes are physically separate from client care areas.
ng areas are equipped with separate cleaning and decontamination work areas as well as storage, dedicated
roper air ventilation.
ions are followed to pre-clean flexible endoscopes immediately at point of use.
exible endoscope is checked for internal and external damage, and if repair is required, the endoscope is prepared
n accordance with manufacturers' instructions.
level disinfection, each flexible endoscope is cleaned, rinsed, and dried according to the manufacturer's instructions.
level disinfection, immersible endoscopic components are soaked and manually cleaned using water and an
re stored in a manner that minimizes contamination and damage.

maintained of the reprocessing history for each flexible endoscope.
opic device reprocessing includes the identification number and the type of endoscope, the identification number of
eprocessor (if applicable), the date and time of reprocessing, the name or unique identifier of the client, the results of
d leak test, and the name of the person reprocessing the endoscope.
duled maintenance, including repairs, is completed and documented for each automated endoscope reprocessor.
E IMPACT OF THE IPC PROGRAM

plan is in place to monitor health care-associated infections.
plan that is in line with applicable regulations, evidence and best practices, and organizational priorities.
ATIONAL PRACTICE: Health care-associated infections are tracked, information is analyzed to identify outbreaks
ation is shared throughout the organization. NOTE: This ROP only applies to organizations
nursing care.
promptly detect suspected health care-associated infections in the organization.
icrobiology laboratory that offers expertise to the organization about identifying health care-associated infections.
receiving and responding to information about suspected health care-associated infections are identified.
f health care-associated infections is investigated.
procedures to contain and prevent the transmission of microorganisms by applying routine practices to all clients and
ecessary.
perts are consulted with to control health care-associated infections, and the necessary information is reported to the
e with the applicable regulations.
nd accepted statistical techniques are used to share and compare information about health care-associated infections.
gations are used to improve programs, policies, or procedures, and to prevent health care-associated infections from
dinated approach for responding to outbreaks.

procedures for identifying and responding to outbreaks in line with applicable regulations.
olunteers are provided with access to policies and procedures for identifying and managing outbreaks.
borates with its partners, such as public health agencies, to define outbreaks in terms of person, place, and time.
es address how to manage emerging, rare, or problematic organisms, including antibiotic-resistant organisms.
procedures about the roles and responsibilities of team members, and volunteers who are involved in identifying and
icated about outbreaks to clients, families, team members, partners, other organizations, and the community when
es are regularly reviewed and improvements are made as needed following each outbreak.
vements to the IPC Program are made.

ovement plan for the IPC program.
sures are monitored.
team members, volunteers, and clients and families on components of the IPC program.
ed about the IPC program is used to identify successes and opportunities for improvement, and to make
ay.
are shared with team members, volunteers, clients, and families.

Unit:

Date:
Tracer Team:
Score Findings/Recommendations
Tracer Tool
OVERALL RESULTS
# of items met: 0
# of items not met: 0
STRENGTHS
CREATING AND SUSTAINING A CARING CULTURE Score

1.0, Services are delivered and decisions made according to the organization's
values and ethics.
1.1, The organization has a values statement.
1.2 The organization's leaders communicate and demonstrate the values throughout the organization.
1.3 Client- and family-centred care is identified as a guiding principle for the organization.
1.4 Teams are supported in their efforts to partner with clients and families in all aspects of their care.
1.5 Policies addressing the rights and responsibilities of clients are developed and implemented with input from clients and
families.
1.6, Input is sought from clients and families during the organization's key decision-making processes.
1.7 An ethics framework to support ethical practice is developed or adopted, and implemented with input from clients and
families.
1.8 The ethics framework defines processes for managing ethics issues, dilemmas, and concerns.
1.9 Accountability for the ethics framework and the processes to address ethics issues is assigned and monitored.
1.10 Support is provided to build the capacity of the governing body, leaders, and teams to use the ethics framework.
1.11 There is a process for gathering and reviewing information about trends in the organization's ethics issues, challenges,
and situations.
1.12 Information about trends in ethics issues, challenges, and situations is used to improve the quality of services.
1.13 The ethics framework includes a process for reviewing the ethical implications of any research activity that the
organization leads or participates in.
1.14 Research projects that the organization leads or participates in are reviewed by an objective reviewer or body.
2.0, A healthy and safe work environment and positive quality of worklife are
promoted and supported.
2.1 A healthy and safe work environment is identified as a strategic priority.
2.2 Support is provided for quality worklife and healthy and safe work environment improvement activities.
2.3 The organization's leaders take part in quality of worklife and healthy and safe work
environment improvement initiatives.
2.4 A code of conduct that applies to all those working in the organization is developed and
implemented.
2.5 A policy regarding reporting, investigating, and resolving behavior that contravenes the code of conduct is developed and
implemented.
2.6 Strategies are developed to help team members to manage their health.
2.7 There is a process in place to support leaders throughout the organization to develop their capabilities to promote a safe
and healthy work environment.
2.8 Continuing professional development and learning is supported.

2.9 Workplace health and safety policies that comply with relevant legislation are developed and implemented.
2.10 An immunization policy and associated procedures, which include recommending specific immunizations for team
members, are developed.
2.11 Team members' fatigue and stress levels are monitored and work is done to reduce safety risks associated with fatigue
and stress.
2.12 REQUIRED ORGANIZATIONAL PRACTICE: A documented and coordinated approach to prevent workplace violence is
implemented.
2.12.1 There is a written workplace violence prevention policy.
2.12.2 The policy is developed in consultation with team members and volunteers as appropriate.
2.12.3 The policy names the individual(s) or position responsible for implementing and monitoring adherence to the policy.
2.12.4 Risk assessments are conducted to ascertain the risk of workplace violence.
2.12.5 There are procedures for team members to confidentially report incidents of workplace violence.
2.12.6 There are procedures to investigate and respond to incidents of workplace violence.
2.12.7 The organization's leaders review quarterly reports of incidents of workplace violence and use this information to
improve safety, reduce incidents of violence, and improve the workplace violence prevention policy.
2.12.8 Information and training is provided to team members on them prevention of workplace violence.
2.13 A process is developed for team members to confidentially bring forward complaints, concerns, and grievances.
2.14 Process and outcome measures related to worklife and the work environment are identified and monitored.
2.15 ACCREDITATION CANADA REQUIRED INSTRUMENT: The quality of the organization's worklife culture is monitored using
the Worklife Pulse Tool.
3.0 A quality improvement culture is promoted throughout the organization.

3.1 Quality improvement is identified as a strategic priority.
3.2 Resources are allocated to support quality improvement activities.
3.3 Teams, clients, and families are supported to develop the knowledge and skills necessary to be involved in quality
improvement activities.
3.4 There are clear, documented processes shared with clients and families about how to file a complaint about the
organization or their care or to report a violation of their rights.
3.5 Opportunities are provided for leaders throughout the organization to participate in collaborative quality improvement
initiatives.
3.6 There are regular dialogues between the organization's leaders and clients and families to solicit and use client and family
perspectives and knowledge on opportunities for improvement.
3.7 The organization's leaders are involved in leading quality improvement initiatives.
3.8 The spread and sustainability of quality improvement results is promoted and supported.
3.9 The organization's leaders promote learning from quality improvement results, and making decisions informed by
research and evidence, client experience, and ongoing quality improvement.
3.10 The organization's leaders promote and support the consistent use of standardized processes, decision-support tools, or
best practice guidelines to reduce variation in and between services, where appropriate.
3.11 Team members, clients, and families who participate in quality improvement initiatives are recognized for their work.
PLANNING AND DESIGNING SERVICES

4.0 Services are planned and designed to meet the needs of the community.
4.1 There is a process to develop or update the mission statement with input from team members, clients, families, and key
stakeholders.
4.2 The organization has a vision and strategic plan.

4.3 Services are planned with input from clients, families, and the broader community.
4.4 When developing the vision and strategic plan, the needs of clients, families, and the broader community, as well as
priorities set by government and other stakeholders, are considered and incorporated where possible.
4.5 When developing the vision and strategic plan, risks and opportunities for the
organization are assessed.
4.6 The strategic plan identifies goals and objectives that are consistent with the mission and values and have measurable
outcomes.
4.7 An ongoing environmental scan is conducted to identify changes and new challenges, and the strategic plan, goals, and
objectives are adjusted as needed, with oversight and guidance from the governing body.
4.8 The organization's mission, vision, and values are shared with team members, clients and families, and the community.
4.9 The strategic goals and objectives are communicated to team members throughout the organization, and to clients and
families.
4.10 Goals and objectives at the team, unit, or program level align with the strategic plan.
4.11 The organization's progress toward achieving the strategic goals and objectives is reported to internal and external
stakeholders and the governing body where applicable.
4.12 Policies and procedures for all of the organization's primary functions, operations, and
systems are documented, authorized, implemented, and up to date.
5.0 The changing needs and health status of the community served are understood.
5.1 Information about the community's health status, capacities, and health care needs is collected or available to the
organization from other sources.
5.2 Information about the community is used to assist in planning the organization's scope of services.
5.3 Information about the community is maintained in a format that is up-to-date and easy to understand.
5.4 Information about the community is shared with the governing body, teams, and stakeholders, including other
organizations, clients, and families.
6.0, Operational plans are developed and implemented to achieve the strategic plan,
goals, and objectives.
6.1 Annual operational plans are developed to support the achievement of the strategic plan, goals, and objectives, and to
guide day-to-day operations.
6.2 When developing the operational plans, input is sought from team members, clients and families, and other
stakeholders, and the plans are communicated throughout the organization.
6.3 The operational plans identify the resources, systems, and infrastructure needed to deliver services and achieve the
strategic plan, goals and objectives.
6.4 The organization's structures and services or program areas are designed, implemented, and adapted as required to
support service delivery and achievement of the operational plans.
6.5 Formal strategies or processes are used to manage change.
6.6 Management systems and tools are used to monitor and report on the implementation of operational plans.
7.0, The organization's leaders collaborate with a broad network of stakeholders.

7.1 The organization's leaders work with the governing body to identify and collaborate with external stakeholders.
7.2 The organization's leaders promote the organization and demonstrate the value of its services to stakeholders and the
community.
7.3 Partnerships are developed with other organizations in the community to efficiently and effectively deliver and
coordinate services.
7.4 The organization's leaders support and participate in ongoing community initiatives to promote health and prevent
disease.
7.5 There is an organization communication plan that addresses disseminating information to and receiving information from
internal and external stakeholders.
7.6 Input is sought from stakeholders on a regular basis to evaluate the effectiveness of their relationships with the
organization.
ALLOCATING RESOURCES AND BUILDING INFRASTRUCTURE

8.0, The organization's financial resources are allocated and managed to maximize
efficiency and meet the service needs of the community.
8.1 Resource allocation is a part of the regular planning cycle for the organization.
8.2 Annual operating and capital budgets are prepared according to the organization's financial policies and
procedures.
8.3 There are opportunities for leaders throughout the organization to receive education on how to manage and
monitor their budgets.
8.4 Input is gathered from external and internal stakeholders when making resource allocation decisions.
8.5 Set criteria are used to guide resource allocation decisions.
8.6 There is a process to have annual operating and capital budgets approved by the governing body.
8.7 There is a process to move resources to where they are needed most within and across operational and service
or program areas.
8.8 The impact of resource allocation decisions is regularly analyzed.
8.9 Budgets are monitored and regular reports are generated on the organization's financial performance.
8.10 Reports on financial performance include an analysis of the utilization of resources and outline opportunities to
improve the effective and efficient use of resources.
8.11 The organization's leaders verify that the organization meets legal requirements for managing financial
resources and financial reporting, e.g., audit, running a deficit.
9.0 The physical environment is safe.

9.1 The physical space meets applicable laws, regulations, and codes.
9.2 There are mechanisms to gather input from clients and families in co-designing new space and determining
optimal use of current space to best support comfort and recovery.
9.3 Client and team health and safety are protected at all times and particularly during periods of construction or
renovation.
9.4 There is a formal and open process for selecting and buying medical devices and equipment, and for selecting
qualified suppliers.
9.5 There is a process to provide education for teams on the safe operation of medical devices and equipment.
9.6 There is a procedure or policy to ensure that team members using specialized medical devices and equipment
are authorized and trained to do so.
9.7 Plans or processes for maintaining, upgrading, and replacing medical devices and equipment are followed.
9.8 REQUIRED ORGANIZATIONAL PRACTICE: A preventive maintenance program for medical devices, medical
equipment, and medical technology is implemented.
9.9 The organization's leaders develop and follow policies and procedures to manage patient safety incidents
involving medical devices, equipment, and technology, including cases involving misuse.
9.10 Steps, including introducing back-up systems, are taken to reduce the impact of utilities failures on client and
team health and safety.
9.11 Initiatives are undertaken to minimize the impact of the organization's operations on the environment.
10.0, The organization invests in its people and supports their professional
development.
10.1 Recruitment and selection of team members is conducted in an equitable manner according to individual
qualifications and their capability to contribute to the organization's values, goals, and objectives.
10.2 Retention strategies are implemented.

10.3 The staffing process used is evidence-based and makes appropriate use of individual skills, education, and
knowledge.
10.4 Education and training are provided throughout the organization to promote and enhance a culture of client-
and family-centred care.
10.5 There is a talent management plan that includes strategies for developing leadership capacity and capabilities
within the organization.
10.6 Reporting relationships are defined for all team members.

10.7 Position profiles are developed for each position and are updated regularly.
10.8 Roles and responsibilities for patient safety are defined in writing.
10.9 REQUIRED ORGANIZATIONAL PRACTICE: Patient safety training and education that addresses specific
patient safety focus areas are provided at least annually to leaders, team members, and volunteers.
10.10 Reporting relationships and leaders' span of control is regularly evaluated.

10.11 Policies and procedures for monitoring team member performance align with the organization's mission,
vision, and values.
10.12 Policies and procedures regarding performance monitoring include how to deal with performance issues in
an objective and fair way.
10.13 An exit interview is offered to team members that leave the organization, and the information is used to
improve performance, staffing, and retention.
10.14 Human resource records are maintained for all team members.
10.15 Human resource records are stored in a manner that protects individual privacy and meets applicable
regulations.
11.0, Information management policies and systems meet current information

needs,take into consideration future information needs, and enhance
organizationalperformance.
11.1 Information management systems selected for the organization meet the organization's current needs and
take into consideration its future needs.
11.2 The privacy and confidentiality of client information are protected, in accordance with applicable legislation.
11.3 Policies and procedures to support the collection, entry, use, reporting, and retention of information are
implemented and reviewed and updated regularly.
11.4 There are policies and processes to allow clients to easily access the information in their health record in a
routine and timely way.
11.5 The organization's leaders manage access to and support and facilitate the flow of clinical and administrative
information throughout the organization, to the governing body, across departments, sites, or regional boundaries,
and to external partners and
the community.
11.6 Teams are provided with timely access to research-based evidence and leading and best practice information.
11.7 The quality and usefulness of the organizations' data and information are regularly assessed, and the
assessment results are used to improve the information systems.
MONITORING AND IMPROVING QUALITY AND SAFETY

12.0 There is a process to manage and mitigate risk in the organization.
12.1 A structured process is used to identify and analyze actual and potential risks or challenges.
12.2 The organization's leaders implement an integrated risk management approach to mitigate and manage risk.
12.3 As part of the integrated risk management approach, the organization's leaders develop risk mitigation plans.
12.4 The risk management approach and contingency plans are disseminated throughout the organization.
12.5 The effectiveness of the integrated risk management approach is regularly evaluated and improvements are
made as necessary.
12.6 As part of the integrated risk management approach, established policies and procedures are followed for
selecting and negotiating contracted services and contracted service providers.
12.7 As part of the integrated risk management approach, the quality of contracted services and contracted service
providers is regularly evaluated.
13.0 Client flow is assessed and improved.

13.1 Client flow information is collected and analyzed in order to identify barriers to optimal client flow, their causes,
and the impact on client experience and safety.
13.2 Information about barriers to client flow is used to develop a strategy to build the organization's capacity to
meet the demand for service and improve client flow throughout the organization.
13.3 The organization's leaders collaborate with other service providers and partners to improve and optimize client
flow.
13.4 REQUIRED ORGANIZATIONAL PRACTICE: Client flow is improved throughout the organization and
emergency department overcrowding is mitigated by working proactively with internal teams and teams from other
sectors. NOTE: This ROP only applies to organizations with an emergency department that can admit clients.
14.0 The organization is prepared for disasters and emergencies.

14.1 Plans for preventing and mitigating potential disasters and emergencies are developed and implemented.
14.2 An all-hazard disaster and emergency response plan is developed and implemented.
14.3 The all-hazard disaster and emergency response plan is aligned with those of partner organizations and local,
regional, and provincial governments.
14.4 Education is provided to support the all-hazard disaster and emergency response plan.
14.5 The organization's all-hazard disaster and emergency response plans are regularly tested with drills and
exercises to evaluate the state of response preparedness.
14.6 The results from post-drill analysis and debriefings are used to review and revise the all-hazard disaster and
emergency response plans and procedures as necessary.
14.7 An incident management system is developed and implemented to direct and coordinate actions and
operations during and after disasters and emergencies.
14.8 An emergency communication plan is developed and implemented.

14.9 A business continuity plan is developed and implemented in order to continue critical operations during and
following a disaster or emergency.
14.9 A business continuity plan is developed and implemented in order to continue critical operations during and
following a disaster or emergency.
14.10 The business continuity plan addresses back-up systems for essential utilities and systems during and
following emergency situations.
14.11 When disasters or emergencies occur, teams, clients, and the community are provided with support and
debriefing opportunities.
15.0 Patient safety is monitored and improved on an ongoing basis.

15.1 REQUIRED ORGANIZATIONAL PRACTICE: A patient safety plan is developed and implemented for the
organization.
15.2 Responsibility for implementing and monitoring the patient safety plan and for leading patient safety
improvement activities is assigned to a council, committee, group, or
individual.
15.3 A strategy to prevent the abuse of clients is developed and implemented.

15.4 REQUIRED ORGANIZATIONAL PRACTICE: A patient safety incident management system that supports
reporting and learning is implemented.
15.5 The organization's leaders support a just culture and provide opportunities for team members to learn from
patient safety incidents.
15.6 REQUIRED ORGANIZATIONAL PRACTICE: A documented and coordinated approach
to disclosing patient safety incidents to clients and families, that promotes
communication and a supportive response, is implemented.
15.7 REQUIRED ORGANIZATIONAL PRACTICE: A documented and coordinated medication reconciliation

process is used to communicate complete and accurate information about medications across care transitions.
15.8 At least one patient safety-related prospective analysis has been conducted within the last year and
appropriate improvements are made as a result.
15.9 ACCREDITATION CANADA REQUIRED INSTRUMENT: The organization's patient

safety culture is monitored by using the Canadian Patient Safety Culture Survey Tool.
15.10 REQUIRED ORGANIZATIONAL PRACTICE: The governing body is provided with
quarterly reports on patient safety that include recommended actions arising out of
patient safety incident analysis, as well as improvements that were made.
16.0, There is a defined and integrated quality management system used to

assessperformance and improve quality.
16.1 An integrated quality improvement plan is developed and implemented.
16.2 A defined process is followed to select and monitor system-level process and outcome measures to evaluate
the organization's performance at a strategic level.
16.3 The organization's leaders require, monitor, and support service, unit, or program areas to monitor their own
process and outcome measures that align with the broader organizational strategic goals and objectives.
16.4 The organization has uploaded a client experience report for applicable services. Please refer to the current
client experience requirement documentation in the client portal for more information.
16.5 Action has been taken on the client experience tool results.
16.6 Opportunities for quality improvement are identified based on trends in patient safety incidents, performance
data, patient experience data, feedback from Client and Family advisory councils and other sources, and plans are
developed to prioritize and address those opportunities.
16.7 The organization's leaders verify that the quality improvement plans and related changes are implemented.
16.8 Regular reports about the organization's performance are generated and shared with the governing body,
where applicable.
16.9 Reports about the organization's performance and quality of services are shared with the team, clients,
families, the community served, and other partners and stakeholders.
16.10 The results of the organization's quality improvement activities are communicated broadly, as appropriate.
Unit:

Date:
Tracer Team:
Findings/Recommendations
Tracer Tool
OVERALL RESULTS
# of items met:
# of items not met:
STRENGTHS
Medication Management
PLANNING THE MEDICATION MANAGEMENT SYSTEM
1.0 An interdisciplinary committee is responsible for managing medications in the
organization.
1.1 The interdisciplinary committee has defined roles and responsibilities for medication
management that are in line with legislation and applicable regulations.
1.2 The interdisciplinary committee includes representatives from a variety of teams

involved in medication management.
1.3 The role of the interdisciplinary committee is regularly evaluated and improvements are
made as needed.
2.0 The interdisciplinary committee oversees the management of medications in the

organization.
2.1 The interdisciplinary committee ensures there is a process to update medication
management policies and procedures based on revisions to applicable laws,
regulations, and standards of practice.
2.2 The interdisciplinary committee has a process to monitor research and best practice
information on medication management and uses the information to update medication
management processes.
2.3 REQUIRED ORGANIZATIONAL PRACTICE: There is an antimicrobial stewardship

program to optimize antimicrobial use.
2.4 The interdisciplinary committee establishes procedures for each step of the medication
management process.
2.5 REQUIRED ORGANIZATIONAL PRACTICE: A documented and coordinated approach
to safely manage high-alert medications is implemented.
2.6 The interdisciplinary committee has policies to oversee the security of all controlled
substances.
2.7 The interdisciplinary committee approves standardized order sets for medications.
2.8 Critical information for medication administration is standardized and is used on
medication orders, medication labels, and in medication administration records.
2.9 The interdisciplinary committee establishes standard medication administration
schedules.
2.10 The interdisciplinary committee shall develop and implement standardized protocols
and/or coupled order sets that permit the emergency administration of all appropriate
antidotes, reversal agents, and rescue agents used in the facility.
2.11 The interdisciplinary committee has a policy on handling sample medications.

2.12 There is a procedure for the use of investigational medications, study medications, and
special access medications.
2.13 There is a procedure to handle medications brought into the organization by clients
and families.
2.14 The organization has a policy and procedure to manage medication shortages.
2.15 The organization has a procedure to determine which medications can be stored in
client service areas.
3.0 Pharmacists are deployed within interprofessional clinical teams and play an
integral and proactive role in client-engaged medication management.
3.1 The organization integrates pharmacists into designated interprofessional clinical
teams to provide proactive care for client-engaged medication management.
3.2 Pharmacists collaborate with clients and interprofessional clinical teams to provide care using evidence-informed care activities associated with improved client and
system outcomes
3.3 The organization has developed local implementation action plans that include prioritizing which high-risk client populations or units receive the evidence-informed care
activities from pharmacists.
4.0 The interdisciplinary committee has a process to determine which medications

can be used in the organization.
4.1 The interdisciplinary committee establishes criteria to add, restrict, and remove medications from the formulary.
4.2 The organization has a process to provide non-formulary medications in a timely manner.
4.3 The interdisciplinary committee reviews and updates the formulary at least every four years.
4.4 The organization has a process to ensure team members and service providers who handle medications are informed about changes to the formulary.
TRAINING AND COMPETENCY EVALUATION

5.0 Teams are educated about how to manage medications.
5.1 Team members participate in orientation prior to their first shift and receive continuing education and training based on their roles and responsibilities for managing
medications within their scope of practice.
5.2 Teams are educated about how to prevent, recognize, respond to, and report patient safety incidents involving medications.
ACCESSING CLIENT AND MEDICATION INFORMATION

6.0 Teams are provided with timely access to client information.
6.1 The team gathers information about allergies and previous adverse drug reactions and it is recorded in the client medication profile, as part of the client record.
6.2 Teams have timely access to the client medication profile and essential client information.
7.0 Teams have timely access to information about medications.

7.1 Teams are provided with access to information about medications.
7.2 Teams can readily access accurate and up-to-date medication information specific to the populations served.
7.3 Teams have access to an on-call pharmacist and prescriber to answer questions about medications or medication management.
8.0 If a computerized prescriber order entry (CPOE) system is used, appropriate and
up-to-date clinical decision support is provided.
8.1 The type of alerts used by the CPOE system includes, at minimum, alerts for medication interactions, medication allergies, and maximum doses for high-alert medications
8.2 A policy is developed and implemented on when and how to override the CPOE system alerts.
8.3 Medication information stored in the CPOE system is updated annually.
8.4 The CPOE system is regularly tested to ensure alerts fire as expected.
8.5 Alert fatigue is managed by regularly evaluating the type of alerts required by the CPOE system based on best practice information and by collecting input from teams.
8.6 The CPOE system is integrated with other information systems used for medication management.
9.0 The pharmacy computer system used to manage medications is up to date and uses appropriate alerts.
9.1 Medication information stored in the pharmacy computer system is updated annually.
9.2 There is a process to determine the type and level of alerts required by the pharmacy computer system that includes, at minimum, alerts for medication interactions,
medication allergies, and minimum and maximum doses for high-alert medications.
9.3 A policy for when and how to override alerts by the pharmacy computer system is developed and implemented.
9.4 Alert fatigue is managed by regularly evaluating the type of alerts required by the pharmacy computer system, based on best practice information and input from teams.
SELECTING AND PROCURING MEDICATIONS

10.0 There is a process to select and procure medications that have received formulary approval.
10.1 The organization works with its partners to encourage differentiation among products with similar labelling and packaging.
10.2 To minimize compounding, the organization purchases commercially manufactured medications when they are available.
10.3 REQUIRED ORGANIZATIONAL PRACTICE: The availability of heparin products is evaluated and limited to ensure that formats with the potential to cause patient safety
incidents are not stocked in client service areas.
10.4 REQUIRED ORGANIZATIONAL PRACTICE: The availability of narcotic products is evaluated and limited to ensure that formats with the potential to cause patient safety
incidents are not stocked in client service areas.
10.5 The organization has a procedure to identify and resolve concerns with medication shipments.
10.6 Medications are returned when they are formally recalled or discontinued by an external body such as a government agency or the manufacturer.
11.0 There is a procedure to select and procure medication delivery devices (e.g., syringes, insulin pens, infusion
pumps).
11.1 There is a procedure to assess, evaluate, document, and reconcile the potential harms
and benefits of medication delivery devices before purchase.
11.2 A decision-making procedure based on a health technology assessment and/or risk

evaluation is used to select medication delivery devices for purchase.
11.3 There are limited brands and models of general purpose infusion pumps, syringe pumps, and patient-controlled analgesia pumps available in the organization.
12.0 A process is in place to maintain and update smart pump libraries.

12.1 Soft- and hard-dose limits are set for all medications administered via infusion.
12.2 A policy that specifies when and how to override smart infusion pump alerts is developed and implemented.
12.3 The medication library DERS stored in the smart infusion pumps is updated and tested periodically.
12.4 Smart infusion pumps undergo periodical maintenance, to ensure functionality of the pumps and the DERS.
12.5 Established dosing limits are reviewed every six months and changes are made as required.
12.6 Clients and families are educated about the risks of tampering with the infusion pump.
STORING MEDICATIONS IN THE PHARMACY AND CLIENT SERVICE AREAS

13.0 Medications are safely stored in the pharmacy and client service areas.
13.1 Access to medication storage areas is limited to authorized team members.
13.2 Medication storage areas are clean and organized.
13.3 The organization has implemented comprehensive procedures for the safe use of medications stored in automated dispensing cabinets (ADCs).
13.4 The organization maintains medication storage conditions that protect the stability of medications.
13.5 Lighting in medication storage areas is sufficient for teams to read medication labels and information sheets.
13.6 Medication storage areas meet legislated requirements and regulations for controlled substances.
13.7 Separate storage in client service areas and in the pharmacy is used for look-alike medications, sound-alike medications, different concentrations of the
same medication, and high-alert medications.
13.8 Pending removal, expired, discontinued, recalled, damaged, or contaminated medications are stored separately in the medication storage areas from
medications that are in use.
13.9 Multi-dose vials are used only for a single client in client service areas.
13.10 REQUIRED ORGANIZATIONAL PRACTICE: The availability of concentrated electrolytes is evaluated and limited to ensure that formats with the potentia
to cause patient safety incidents are not stocked in client service areas.
13.11 Medication storage areas are regularly inspected, and improvements are made if needed.
14.0 Hazardous medications are safely stored in client service areas and medication
preparation areas.
14.1 Raw materials used for compounding are regularly assessed to determine if they should be discarded when they are not regularly used or are considered
dangerous.
14.2 Regulations for handling raw materials used for compounding in the pharmacy, including storage and cleaning up spills, are followed.
14.3 Chemotherapy medications are stored in a separate negative pressure room with adequate ventilation and are segregated from other supplies where
possible.
14.4 Anesthetic gases and volatile liquid anesthetic agents are stored in an area with adequate ventilation, as per the manufacturer's instructions.
PRESCRIBING AND ORDERING MEDICATIONS

15.0 Medications are prescribed and ordered safely, and the technical requirements of the medication order are met.
15.1 A structured program has been implemented to reduce the risks associated with polypharmacy, especially with frail or vulnerable clients.
15.2 The team regularly evaluates intravenous therapy in clients using an established intravenous to oral conversion program that has been approved by the
interdisciplinary committee.
15.3 A standardized procedure is followed when sending medication orders to the pharmacy.
15.4 Standardized, pre-printed forms shall be used to order medications that are commonly prescribed or have been identified as high risk.
15.5 There is a policy for acceptable medication orders, with criteria being developed or revised, implemented, and regularly evaluated, and the policy is revised
as necessary.
15.6 REQUIRED ORGANIZATIONAL PRACTICE: A list of abbreviations, symbols, and dose designations that are not to be used have been identified and
implemented.
15.7 Disease-specific protocols and pre-printed or electronic orders are used for chemotherapy orders.
15.8 Steps are taken to reduce distractions, interruptions, and noise when team members,are prescribing medications or transcribing and verifying medication
orders.
15.9 There is a policy on telephone and verbal orders for medications that specifies when such orders are acceptable, how they are to be documented, and whe
they are to be co-signed by the prescriber.
15.10 Medication orders are accurately transcribed into clinical documents such as medication administration records.
15.11 The organization uses regular, documented audits to assess the accuracy of medication order documentation and makes improvements as needed as pa
of a continuous quality improvement program.
PREPARING MEDICATIONS
16.0 The pharmacist reviews all medication orders for accuracy and appropriateness
16.1 The pharmacist reviews each medication order prior to the first dose being administered
16.2 The pharmacist performs an independent double check for the dosing calculations of pediatric weight-based protocols.
16.3 The pharmacist performs an independent double check for the dosing calculations for chemotherapeutic agents that are dosed according to weight or body
surface area.
16.4 A team member contacts the prescriber if there are concerns about or changes required to a medication order and documents the results of the discussion
(e.g., a corrected medication order) in the client record.
17.0 Medications are safely and appropriately prepared.

17.1 Medication preparation areas are clean and organized.
17.2 Appropriate ventilation, temperature, and lighting are maintained in the medication preparation areas.
17.3 There is a separate negative pressure area for preparing hazardous medications, with a 100 percent externally vented biological safety cabinet.
17.4 Sterile products are prepared in a separate area that meets standards for aseptic compounding.
17.5 Direct contact with hazardous medications is avoided while the medications are being prepared.
17.6 Accurate and up-to-date records are maintained for all medications that are compounded or repackaged in the pharmacy.
17.7 Accurate and up-to-date information is maintained for all medications dispensed by the pharmacy or client service area, and includes, at minimum, the date
and quantity.
LABELLING AND PACKAGING MEDICATIONS

18.0 The likelihood of patient safety incidents involving medications is reduced through appropriate medication
labelling, packaging, and nomenclature.
18.1 Medication packages or units are labelled in a standardized manner.
18.2 The organization labels all sterile products with a label that, at minimum, includes the name of the medication, the base solution, and the total amount of
medication additives.
18.3 Unit dose oral medications are kept in manufacturer or pharmacy packaging until they are administered.
18.4 Concerns with medication names, packaging, or labelling are identified, reported to the pharmacy or manufacturer, and shared with team members in the
pharmacy and in client service areas.
DISPENSING AND DELIVERING MEDICATIONS

19.0 Medications are dispensed in a safe, secure, and timely manner.
19.1 The pharmacy has a quality assurance process to ensure that medications are accurately dispensed as ordered.
19.2 Medications are dispensed in unit dose packaging and exclusions (e.g., liquids, topical preparations, antacids, otic/ophthalmics, multi-dose vials) are
specified in organizational policy.
19.3 Emergency, urgent, and routine medications are accessible within the timelines set by the organization.
19.4 When automated dispensing cabinets are used, there are policies and procedures that address access, location, type of medication information, verification
and restocking of medications.
19.5 Automated dispensing cabinets in client service areas interface with the medication order entry management system.
20.0 The organization has a process for controlled access to medications when the pharmacy is closed.
20.1 When the pharmacy is closed, there is controlled access to a night cabinet or to automated dispensing cabinet for a limited selection of urgently required
medications.
20.2 A record is kept of the medications accessed from the night cabinet or automated dispensing cabinet.
20.3 A pharmacist or other qualified team member verifies, as soon as possible, that the correct medications were obtained from the automated dispensing
cabinet or night cabinet after hours.
20.4 The system for dispensing medications when the pharmacy is closed is regularly evaluated and improvements are made as needed.
21.0 Medications are transported in a safe, secure, and timely manner.

21.1 Medications are delivered securely from the pharmacy to client service areas.
21.2 Steps are taken to protect the health and safety of team members who transport, administer, or dispose of cytotoxic or other hazardous medications.
21.3 A readily accessible hazardous spill kit is located wherever cytotoxic or other hazardous medications are dispensed and administered.
21.4 There is a procedure to manage the return of medications to the pharmacy.
21.5 The organization has a policy and procedure to manage how it procures and tracks medications.
ADMINISTERING MEDICATION AND CLIENT MONITORING

22.0 The team works with clients and families to safely administer medications.
22.1 The team discusses medications prior to the initial dose and when the dose is adjusted, documents the discussion, and gives highest priority to the wishes
of the client or family.
22.2 At the time of admission, information on how to prevent patient safety incidents involving medications is provided to and discussed with clients and families
22.3 Information is shared with each client about who to contact and how to reach that person if they have concerns or questions about their medications while
receiving care, at transfer of service, or at the end of service.
22.4 Team members reinforce medication information that is provided to clients and families and respond to concerns or questions they may have about their
medication.
23.0 The organization works with clients and families to manage self-administration of
medications safely.
23.1 There is a policy and procedure to ensure client self-administration of medication is safely managed.
23.2 Established criteria are used to determine which medications clients can selfadminister.
23.3 Established criteria are used to assess whether a client is able to self-administer medications.
23.4 Medications that are self-administered by clients are stored and labelled safely and appropriately.
23.5 Each client who self-administers medications is provided with appropriate education and supervision prior to self-administration, and this is documented in
the client record.
23.6 The process for self-administering medications includes documenting in the client record that the client took the medication and when it was taken.
24.0 The organization has processes to ensure medications are administered safely and accurately.
24.1 Team members who administer medications are assigned a level of responsibility that is within their scope of practice
24.2 Before medication is administered, the client’s profile is consulted to verify the “rights” of medication administration, which are the right medication, the righ
dose, the right route, the right time, to the right person, with the right documentation, for the right reason, and with the right response.
24.3 The organization establishes a list of high-alert medications that require an independent double check before they are administered.
24.4 An independent double check of high-alert medications identified by the organization is conducted at the point of care before these medications are
administered.
24.5 To allow for immediate administration during emergencies, antidotes, reversal agents, and rescue agents shall be available to team members along with
standardized protocols or coupled order sets and directions for use.
24.6 When using medications intended for the topical use in surgical procedures, such as concentrated epinephrine, it is not drawn up into a parenteral syringe
but placed in a labelled bowl within the sterile field.
24.7 When using any medication intended for injection, it is drawn into the syringe from the original vial and labelled immediately prior to use.
24.8 In the event of a delayed or missed medication dose, the team documents the actual time of administration in the client record.
24.9 Teams address medication-related concerns with a prescriber or pharmacist and follow established guidelines to notify the prescriber or pharmacist as
required.
24.10 Lot numbers and expiry dates for vaccines are documented in the client record following administration of the medication.
25.0 There are policies and procedures to ensure team members are competent to safely assist clients with their
medications.
25.1 Team members who assist with medications are provided with appropriate training, at orientation and on an ongoing basis, to maintain competency.
25.2 Team members who assist with medications are educated on how to recognize allergic reactions and how to respond if a reaction occurs.
25.3 Team members who assist with medications have access to a regulated health care professional who can answer their questions about medications.
26.0 Clients are monitored following medication administration.

26.1 The team has access to up-to-date reference material that identifies the type and frequency of monitoring required for specific medications.
26.2 The effects of medications on client treatment goals are monitored and documented in the client record.
26.3 Clients are monitored for possible patient safety incidents involving medications.
26.4 Alerts or alarms on client monitoring systems are used to alert team members and service providers immediately of potential patient safety incidents.
26.5 The organization discloses patient safety incidents involving medications to the client and family at the earliest opportunity.
EVALUATING THE MEDICATION MANAGEMENT SYSTEM

27.0 The interdisciplinary committee uses the organization's patient safety incident management system to report and
learn from patient safety incidents involving medications.
27.1 The interdisciplinary committee maintains the organization's patient safety incident management system and ensures it is used to report patient safety
incidents involving medications.
27.2 All patient safety incidents and near misses are reported, reviewed, and analyzed.
27.3 The interdisciplinary committee reviews patient safety incidents involving medications and uses established criteria to prioritize those that will be analyzed
further.
27.4 The interdisciplinary committee determines which team members to involve in the analysis of patient safety incidents involving medications.
27.5 In response to patient safety incidents involving medications, the interdisciplinary committee exchanges information with clients, families, and other team
members about recommended actions and improvements that were made.
28.0 Adverse drug reactions are monitored and reported.

28.1 Teams are informed about the value of and their role in reporting adverse drug reactions, specifically unexpected, expected, or serious reactions to recently
marketed medications.
28.2 Teams are provided with information on how to identify and report adverse drug reactions.
28.3 Action plans are developed in response to alerts regarding adverse drug reactions.
29.0 The interdisciplinary committee oversees a quality improvement program for medication management.
29.1 Resources are provided to support quality improvement activities for medication management.
29.2 When medication management processes are contracted to external providers, a contract is established and maintained with each provider that requires
consistent
29.3 Whenlevels of quality
medication and adherence
management to accepted
processes standards
are contracted to of practice.
external providers, the quality of the services is regularly monitored by reviewing the evidence
from the external contractors.
29.4 The interdisciplinary committee conducts an annual evaluation of the medication management system.
29.5 The interdisciplinary committee monitors process and outcome indicators for medication management.
29.6 The interdisciplinary committee prioritizes and completes medication use evaluations.
29.7 The interdisciplinary committee uses the information it collects about its medication management system to identify successes and opportunities for
improvement, and to ensure that improvements are made in a timely way.
29.8 The interdisciplinary committee shares evaluation results, areas of success, and opportunities for improvement with teams.
own list.
ection.
elections
0
0
gement Score
MEDICATION MANAGEMENT SYSTEM
ary committee is responsible for managing medications in the
mittee has defined roles and responsibilities for medication
with legislation and applicable regulations.
mittee includes representatives from a variety of teams

ement.
inary committee is regularly evaluated and improvements are
nary committee oversees the management of medications in the
mittee ensures there is a process to update medication

cedures based on revisions to applicable laws,
practice.
mittee has a process to monitor research and best practice

anagement and uses the information to update medication
NAL PRACTICE: There is an antimicrobial stewardship

obial use.
mittee establishes procedures for each step of the medication
NAL PRACTICE: A documented and coordinated approach

edications is implemented.
mittee has policies to oversee the security of all controlled
mittee approves standardized order sets for medications.

dication administration is standardized and is used on
n labels, and in medication administration records.
mittee establishes standard medication administration
mittee shall develop and implement standardized protocols

t permit the emergency administration of all appropriate
d rescue agents used in the facility.
mittee has a policy on handling sample medications.

the use of investigational medications, study medications, and
andle medications brought into the organization by clients
olicy and procedure to manage medication shortages.

ocedure to determine which medications can be stored in
deployed within interprofessional clinical teams and play an

ve role in client-engaged medication management.
s pharmacists into designated interprofessional clinical
re for client-engaged medication management.
ith clients and interprofessional clinical teams to provide care using evidence-informed care activities associated with improved client and
loped local implementation action plans that include prioritizing which high-risk client populations or units receive the evidence-informed care
nary committee has a process to determine which medications

rganization.
mittee establishes criteria to add, restrict, and remove medications from the formulary.
cess to provide non-formulary medications in a timely manner.
mittee reviews and updates the formulary at least every four years.
cess to ensure team members and service providers who handle medications are informed about changes to the formulary.
MPETENCY EVALUATION
ted about how to manage medications.
e in orientation prior to their first shift and receive continuing education and training based on their roles and responsibilities for managing
e of practice.
t how to prevent, recognize, respond to, and report patient safety incidents involving medications.
AND MEDICATION INFORMATION

ded with timely access to client information.
tion about allergies and previous adverse drug reactions and it is recorded in the client medication profile, as part of the client record.
to the client medication profile and essential client information.
ly access to information about medications.

access to information about medications.
ccurate and up-to-date medication information specific to the populations served.
n-call pharmacist and prescriber to answer questions about medications or medication management.
d prescriber order entry (CPOE) system is used, appropriate and

ecision support is provided.
the CPOE system includes, at minimum, alerts for medication interactions, medication allergies, and maximum doses for high-alert medications.
mplemented on when and how to override the CPOE system alerts.

ored in the CPOE system is updated annually.
rly tested to ensure alerts fire as expected.
y regularly evaluating the type of alerts required by the CPOE system based on best practice information and by collecting input from teams.
ated with other information systems used for medication management.
omputer system used to manage medications is up to date and uses appropriate alerts.
ored in the pharmacy computer system is updated annually.
mine the type and level of alerts required by the pharmacy computer system that includes, at minimum, alerts for medication interactions,
mum and maximum doses for high-alert medications.
to override alerts by the pharmacy computer system is developed and implemented.

y regularly evaluating the type of alerts required by the pharmacy computer system, based on best practice information and input from teams.
PROCURING MEDICATIONS
ess to select and procure medications that have received formulary approval.
with its partners to encourage differentiation among products with similar labelling and packaging.
g, the organization purchases commercially manufactured medications when they are available.
NAL PRACTICE: The availability of heparin products is evaluated and limited to ensure that formats with the potential to cause patient safety
ent service areas.
NAL PRACTICE: The availability of narcotic products is evaluated and limited to ensure that formats with the potential to cause patient safety
ent service areas.
ocedure to identify and resolve concerns with medication shipments.
d when they are formally recalled or discontinued by an external body such as a government agency or the manufacturer.
edure to select and procure medication delivery devices (e.g., syringes, insulin pens, infusion
ssess, evaluate, document, and reconcile the potential harms

livery devices before purchase.
dure based on a health technology assessment and/or risk

edication delivery devices for purchase.
and models of general purpose infusion pumps, syringe pumps, and patient-controlled analgesia pumps available in the organization.
place to maintain and update smart pump libraries.

s are set for all medications administered via infusion.
en and how to override smart infusion pump alerts is developed and implemented.
ERS stored in the smart infusion pumps is updated and tested periodically.
dergo periodical maintenance, to ensure functionality of the pumps and the DERS.
are reviewed every six months and changes are made as required.
ducated about the risks of tampering with the infusion pump.
ATIONS IN THE PHARMACY AND CLIENT SERVICE AREAS

afely stored in the pharmacy and client service areas.
storage areas is limited to authorized team members.
s are clean and organized.
mplemented comprehensive procedures for the safe use of medications stored in automated dispensing cabinets (ADCs).
tains medication storage conditions that protect the stability of medications.
storage areas is sufficient for teams to read medication labels and information sheets.
eas meet legislated requirements and regulations for controlled substances.
ent service areas and in the pharmacy is used for look-alike medications, sound-alike medications, different concentrations of the
alert medications.
red, discontinued, recalled, damaged, or contaminated medications are stored separately in the medication storage areas from
ed only for a single client in client service areas.

ZATIONAL PRACTICE: The availability of concentrated electrolytes is evaluated and limited to ensure that formats with the potential
ents are not stocked in client service areas.
reas are regularly inspected, and improvements are made if needed.
ications are safely stored in client service areas and medication
r compounding are regularly assessed to determine if they should be discarded when they are not regularly used or are considered
ng raw materials used for compounding in the pharmacy, including storage and cleaning up spills, are followed.
tions are stored in a separate negative pressure room with adequate ventilation and are segregated from other supplies where
volatile liquid anesthetic agents are stored in an area with adequate ventilation, as per the manufacturer's instructions.
ND ORDERING MEDICATIONS
prescribed and ordered safely, and the technical requirements of the medication order are met.
has been implemented to reduce the risks associated with polypharmacy, especially with frail or vulnerable clients.
aluates intravenous therapy in clients using an established intravenous to oral conversion program that has been approved by the
ure is followed when sending medication orders to the pharmacy.

ted forms shall be used to order medications that are commonly prescribed or have been identified as high risk.
ceptable medication orders, with criteria being developed or revised, implemented, and regularly evaluated, and the policy is revised
ATIONAL PRACTICE: A list of abbreviations, symbols, and dose designations that are not to be used have been identified and
cols and pre-printed or electronic orders are used for chemotherapy orders.
uce distractions, interruptions, and noise when team members,are prescribing medications or transcribing and verifying medication
ephone and verbal orders for medications that specifies when such orders are acceptable, how they are to be documented, and when
the prescriber.
e accurately transcribed into clinical documents such as medication administration records.

s regular, documented audits to assess the accuracy of medication order documentation and makes improvements as needed as part
ovement program.
DICATIONS
reviews all medication orders for accuracy and appropriateness
s each medication order prior to the first dose being administered
ms an independent double check for the dosing calculations of pediatric weight-based protocols.
ms an independent double check for the dosing calculations for chemotherapeutic agents that are dosed according to weight or body
cts the prescriber if there are concerns about or changes required to a medication order and documents the results of the discussion
n order) in the client record.
safely and appropriately prepared.

n areas are clean and organized.
, temperature, and lighting are maintained in the medication preparation areas.
gative pressure area for preparing hazardous medications, with a 100 percent externally vented biological safety cabinet.
epared in a separate area that meets standards for aseptic compounding.

ardous medications is avoided while the medications are being prepared.
te records are maintained for all medications that are compounded or repackaged in the pharmacy.
te information is maintained for all medications dispensed by the pharmacy or client service area, and includes, at minimum, the date
PACKAGING MEDICATIONS
of patient safety incidents involving medications is reduced through appropriate medication
, and nomenclature.
or units are labelled in a standardized manner.
s all sterile products with a label that, at minimum, includes the name of the medication, the base solution, and the total amount of
ions are kept in manufacturer or pharmacy packaging until they are administered.
ion names, packaging, or labelling are identified, reported to the pharmacy or manufacturer, and shared with team members in the
ice areas.
D DELIVERING MEDICATIONS
dispensed in a safe, secure, and timely manner.
uality assurance process to ensure that medications are accurately dispensed as ordered.
nsed in unit dose packaging and exclusions (e.g., liquids, topical preparations, antacids, otic/ophthalmics, multi-dose vials) are
olicy.
d routine medications are accessible within the timelines set by the organization.
ensing cabinets are used, there are policies and procedures that address access, location, type of medication information, verification,
ns.
cabinets in client service areas interface with the medication order entry management system.
n has a process for controlled access to medications when the pharmacy is closed.
closed, there is controlled access to a night cabinet or to automated dispensing cabinet for a limited selection of urgently required
medications accessed from the night cabinet or automated dispensing cabinet.
qualified team member verifies, as soon as possible, that the correct medications were obtained from the automated dispensing
r hours.
sing medications when the pharmacy is closed is regularly evaluated and improvements are made as needed.
transported in a safe, secure, and timely manner.

red securely from the pharmacy to client service areas.
ect the health and safety of team members who transport, administer, or dispose of cytotoxic or other hazardous medications.
azardous spill kit is located wherever cytotoxic or other hazardous medications are dispensed and administered.
o manage the return of medications to the pharmacy.
a policy and procedure to manage how it procures and tracks medications.
MEDICATION AND CLIENT MONITORING

with clients and families to safely administer medications.
edications prior to the initial dose and when the dose is adjusted, documents the discussion, and gives highest priority to the wishes
n, information on how to prevent patient safety incidents involving medications is provided to and discussed with clients and families.
with each client about who to contact and how to reach that person if they have concerns or questions about their medications while
f service, or at the end of service.
ce medication information that is provided to clients and families and respond to concerns or questions they may have about their
n works with clients and families to manage self-administration of
rocedure to ensure client self-administration of medication is safely managed.

e used to determine which medications clients can selfadminister.
e used to assess whether a client is able to self-administer medications.
elf-administered by clients are stored and labelled safely and appropriately.
dministers medications is provided with appropriate education and supervision prior to self-administration, and this is documented in
dministering medications includes documenting in the client record that the client took the medication and when it was taken.
n has processes to ensure medications are administered safely and accurately.

dminister medications are assigned a level of responsibility that is within their scope of practice
dministered, the client’s profile is consulted to verify the “rights” of medication administration, which are the right medication, the right
ht time, to the right person, with the right documentation, for the right reason, and with the right response.
blishes a list of high-alert medications that require an independent double check before they are administered.
e check of high-alert medications identified by the organization is conducted at the point of care before these medications are
administration during emergencies, antidotes, reversal agents, and rescue agents shall be available to team members along with
oupled order sets and directions for use.
ns intended for the topical use in surgical procedures, such as concentrated epinephrine, it is not drawn up into a parenteral syringe
l within the sterile field.
ation intended for injection, it is drawn into the syringe from the original vial and labelled immediately prior to use.
ed or missed medication dose, the team documents the actual time of administration in the client record.
ation-related concerns with a prescriber or pharmacist and follow established guidelines to notify the prescriber or pharmacist as
ry dates for vaccines are documented in the client record following administration of the medication.
es and procedures to ensure team members are competent to safely assist clients with their
ssist with medications are provided with appropriate training, at orientation and on an ongoing basis, to maintain competency.
ssist with medications are educated on how to recognize allergic reactions and how to respond if a reaction occurs.
ssist with medications have access to a regulated health care professional who can answer their questions about medications.
itored following medication administration.

o up-to-date reference material that identifies the type and frequency of monitoring required for specific medications.
ons on client treatment goals are monitored and documented in the client record.
or possible patient safety incidents involving medications.
ent monitoring systems are used to alert team members and service providers immediately of potential patient safety incidents.
oses patient safety incidents involving medications to the client and family at the earliest opportunity.
E MEDICATION MANAGEMENT SYSTEM

inary committee uses the organization's patient safety incident management system to report and
afety incidents involving medications.
ommittee maintains the organization's patient safety incident management system and ensures it is used to report patient safety
ons.
ents and near misses are reported, reviewed, and analyzed.
ommittee reviews patient safety incidents involving medications and uses established criteria to prioritize those that will be analyzed
ommittee determines which team members to involve in the analysis of patient safety incidents involving medications.
safety incidents involving medications, the interdisciplinary committee exchanges information with clients, families, and other team
ded actions and improvements that were made.
eactions are monitored and reported.

bout the value of and their role in reporting adverse drug reactions, specifically unexpected, expected, or serious reactions to recently
th information on how to identify and report adverse drug reactions.

oped in response to alerts regarding adverse drug reactions.
inary committee oversees a quality improvement program for medication management.

d to support quality improvement activities for medication management.
agement processes are contracted to external providers, a contract is established and maintained with each provider that requires
and adherence
agement to accepted
processes standards
are contracted to of practice.
external providers, the quality of the services is regularly monitored by reviewing the evidence
s.
ommittee conducts an annual evaluation of the medication management system.
ommittee monitors process and outcome indicators for medication management.

ommittee prioritizes and completes medication use evaluations.
ommittee uses the information it collects about its medication management system to identify successes and opportunities for
e that improvements are made in a timely way.
ommittee shares evaluation results, areas of success, and opportunities for improvement with teams.
Unit:

Date:
Tracer Team:
Tracer Tool
OVERALL RESULTS
# of items met:
# of items not met:
STRENGTHS
BUILDING A PREPARED AND COMPETENT TEAM

1.0 Team members are qualified and have relevant competencies.
1.1 Orientation to the unique work environment in the emergency department is provided to new team members.
1.2 Education and support to work with clients with mental health and addictions are provided to team members.
1.3 Training specific to providing emergency health services to pediatric clients is provided to the team.
1.4 Consultants and referring medical professionals are part of the collaborative team and work with the emergency department team to coordinate services or transfers.
1.5 Workload is assessed and team members are reassigned as required during periods of high volume and surges in the emergency department.
PROVIDING SAFE AND EFFECTIVE SERVICES

2.0 Client flow through the emergency department is managed.
2.1 Client flow throughout the organization is addressed and managed in collaboration with organizational leaders, and with input from clients and families.
2.2 A proactive approach is taken to prevent and manage overcrowding in the emergency department, in collaboration with organizational leaders, and with input from clien
families.
2.3 Timely access for clients is coordinated with other services and teams within the organization.
2.4 There is access to the emergency department 24 hours a day, seven days a week.
2.5 Barriers within the emergency department that impede clients, families, providers, and referring organizations from accessing services are identified and addressed, with
clients and families.
2.6 Comprehensive emergency services are provided in collaboration with partners.
2.7 Procedures for transport of high-risk clients are established with Emergency Medical Service (EMS) providers.
2.8 Standardized processes and procedures are followed to coordinate timely inter-facility client transfers and transfers to other teams within the organization.
2.9 Discharge planning is completed with other health care services and includes information about referrals.
2.10 There are established protocols to identify and manage overcrowding and surges in the emergency department.
2.11 Protocols to move clients elsewhere within the organization during times of overcrowding are followed by the team.
2.12 Protocols are followed to manage clients when access to inpatient beds is not available.
2.13 Protocols to manage overcrowding and surges are followed before requesting aid from alternative health care sites or diverting ambulances.
3.0 Access to services for current and potential clients, families, teams, and referring organizations is provided in a tim
and coordinated manner.
3.1 Entrance(s) to the emergency department are clearly marked and accessible.
3.2 All clients who present at the emergency department are evaluated.
3.3 Clients are offloaded from Emergency Medical Services (EMS) and an initial assessment is conducted and documented by a nurse or other medical professional in a timely
3.4 Pertinent client information is transferred in collaboration with Emergency Medical Services (EMS).
3.5 Equipment and supplies that are appropriate for pediatric clients are available and accessible.
4.0 Clients in the emergency department are triaged in a timely way.

4.1 A standardized tool is used to conduct the triage assessment.
4.2 A standardized pediatric-specific tool is used to conduct the triage assessment of pediatric clients.
4.3 A triage assessment for each client is completed and documented within established timelines, and in partnership with the client and family.
4.4 A triage assessment for each pediatric client is conducted within established timelines, and in partnership with the client and family.
4.5 After triage, the client's immediate and urgent needs are identified and priorities of service are determined using set criteria, with input from the client's other service pro
in partnership with the client and family.
4.6 After the initial triage assessment, clients who are waiting for service are advised which team member to contact if their condition changes.
4.7 There is ongoing communication with clients who are waiting for services.
4.8 Clients waiting in the emergency department are monitored for possible deterioration of condition and are reassessed as appropriate.
5.0 Clients and families are partners in service delivery.

5.1 There is an open, transparent, and respectful relationship with each client.
5.2 Clients and families are encouraged to be actively engaged in their care.
5.3 The capacity of each client to be involved in their care is determined in partnership with the client and family.
5.4 The client's wishes regarding family involvement in their care are respected and followed.
5.5 Complete and accurate information is shared with the client and family in a timely way, in accordance with the client's desire to be involved.
5.6 The team verifies that the client and family understand information provided about their care.
5.7 Translation and interpretation services are available for clients and families as needed.
5.8 Seclusion rooms and/or private and secure areas are available for clients.
5.9 The client's capacity to provide informed consent is determined.
5.10 The client's informed consent is obtained and documented before providing services.
5.11 When clients are incapable of giving informed consent, consent is obtained from a substitute decision maker.
5.12 Clients and families are provided with opportunities to be engaged in research activities that may be appropriate to their care.
5.13 Ethics-related issues are proactively identified, managed, and addressed.
5.14 There is a policy and process to manage medico-legal issues in the emergency department.
5.15 Clients and families are provided with information about their rights and responsibilities.
5.16 Clients and families are provided with information about how to file a complaint or report violations of their rights.
5.17 A process to investigate and respond to claims that clients' rights have been violated is developed and implemented with input from clients and families.
6.0 Clients who present to the emergency department are effectively assessed.
6.1 Each client's physical and psychosocial health is assessed and documented using a holistic approach, in partnership with the client and family.
6.2 The assessment process is designed with input from clients and families.
6.3 Goals and expected results of the client's care and services are identified in partnership with the client and family.
6.4 Standardized assessment tools are used during the assessment process.
6.5 REQUIRED ORGANIZATIONAL PRACTICE:In partnership with clients, families, or caregivers (as appropriate), the medication reconciliation process is initiated for clients wit
to admit, and can be completed on the receiving unit.
6.6 Universal fall precautions, applicable to the setting, are identified and implemented to ensure a safe environment that prevents falls and reduces the risk of injuries from
6.7 REQUIRED ORGANIZATIONAL PRACTICE:Clients are assessed and monitored for risk of suicide.
6.8 Each client's preferences and options for services are discussed as part of the assessment, in partnership with the client and family.
6.9 Options and preferences for pain management are discussed with the client.
6.10 An assessment of the client's palliative and end-of-life care needs is completed, where appropriate, in partnership with the client and family.
6.11 Priority access to diagnostic services and laboratory testing and results is available 24 hours a day, 7 days a week.
6.12 Evidence-based protocols are used to select diagnostic imaging services for pediatric clients.
6.13 Urgent medications and pharmacy staff can be accessed 24 hours a day, 7 days a week.
6.14 Priority access to consultation services is available 24 hours a day, 7 days a week.
6.15 There is timely access to specialists with expertise in pediatric health.
6.16 A process is followed to communicate and validate client diagnoses when there is discrepancy between the initial diagnosis and diagnostic imaging or laboratory results.
6.17 The client's health status is reassessed in partnership with the client, and updates are documented in the client record, particularly when there is a change in health stat
6.18 The results of the assessment are shared with the client and other team members in a timely and easy-to-understand way.
6.19 A comprehensive and individualized care plan is developed and documented in partnership with the client and family.
6.20 Client progress toward achieving goals and expected results is monitored in partnership with the client, and the information is used to adjust the care plan as necessary.
6.21 Planning for care transitions, including end of service, are identified in the care plan in partnership with the client and family.
7.0 Potential organ and tissue donors are identified and referred in a timely and effective manner.
7.1 There are established protocols and policies on organ andmtissue donation.
7.2 There is a policy on neurological determination of death (NDD).
7.3 There is a policy to transfer potential organ donors to another level of care once they have been identified.
7.4 There are established clinical referral triggers to identify potential organ and tissue donors.
7.5 Training and education on organ and tissue donation and the role of the organization and the emergency department is provided to the team.
7.6 Training and education on how to support and provide information to families of potential organ and tissue donors is provided to the team, with input from clients and fa
7.7 When death is imminent or established for potential donors, the Organ Procurement Organization (OPO) or tissue centre is notified in a timely manner.
7.8 All aspects of the donation process are recorded in the client record, including the family's decision about organ and tissue donation.
8.0 Safe and effective care is provided to clients in the emergency department.
8.1 The client's individualized care plan is followed when services are provided.
8.2 All services received by the client, including changes and adjustments to the care plan, are documented in the client record.
8.3 Client privacy is respected during registration.
8.4 An established procedure, such as the use of armbands, is used to identify clients in the emergency department.
8.5 Assigned roles and responsibilities are adhered to during the resuscitation of clients.
8.6 REQUIRED ORGANIZATIONAL PRACTICE:Working in partnership with clients and families, at least two personspecific identifiers are used to confirm that clients receive the
procedure intended for them.
8.7 Treatment protocols are consistently followed to provide the same standard of care in all settings to all clients.
8.8 Clients with known or suspected infectious diseases are identified, isolated, and managed.
8.9 Clients who have received sedatives or narcotics are monitored.
8.10 Emergency and advanced resuscitation equipment, supplies, and materials are available in the room where procedural sedation is administered.
8.11 Information on pediatric medication dosages is available and accessible to the team.
8.12 Medications are administered to pediatric clients using weight-based pediatric dosages and appropriately sized equipment.
8.13 Access to spiritual space and care is provided to meet clients' needs.
8.14 Clients and families have access to psychosocial and/or supportive care services, as required.
8.15 There is a process for initiating palliative and end-of-life care, as required.
8.16 Support for the family, team members, and other clients is provided throughout and following the death of a client.
8.17 REQUIRED ORGANIZATIONAL PRACTICE:Information relevant to the care of the client is communicated effectively during care transitions.
8.18 Information obtained from Emergency Medical Services, triage, assessment, and admissions is transferred to service providers in the next setting.
9.0 Clients and families are partners in planning and preparing for transition to another service or setting.
9.1 Clients and families are actively engaged in planning and preparing for transitions in care.
9.2 Clinical guidelines are used to determine whether a client is fit for transfer of care.
9.3 The client's physical and psychosocial readiness for transition, including their capacity to self-manage their health, is assessed.
9.4 Clients are empowered to self-manage conditions by receiving education, tools, and resources, where applicable.
9.5 Appropriate follow-up services for the client, where applicable, are coordinated in collaboration with the client, family, other teams, and organizations.
9.6 The transition plan is documented in the client record.
9.7 A client's wish to end or limit services, transfer to another service, or transition home, is respected.
9.8 The client's risk of readmission is assessed, where applicable, and appropriate follow-up is coordinated.
9.9 The effectiveness of transitions is evaluated and the information is used to improve transition planning, with input from clients and families.
MONITORING QUALITY AND ACHIEVING POSITIVE OUTCOMES

10.0 Indicator data is collected and used to guide quality improvement activities.
10.1 Specific goals and objectives regarding wait times, length of stay (LOS) in the emergency department, client diversion to other facilities, and number of clie
leave without being seen are established, with input from clients and
families.
10.2 Ambulance offload response times are measured and used to set target times for clients brought to the emergency department by Emergency Medical Serv
10.3 Data on wait times for services, the length of stay in the emergency department, and the number of clients who leave without being seen is tracked and ben
own list.
ection.
elections
0
0
PARED AND COMPETENT TEAM Score

are qualified and have relevant competencies.
work environment in the emergency department is provided to new team members.
work with clients with mental health and addictions are provided to team members.
ng emergency health services to pediatric clients is provided to the team.
medical professionals are part of the collaborative team and work with the emergency department team to coordinate services or transfers.
team members are reassigned as required during periods of high volume and surges in the emergency department.
E AND EFFECTIVE SERVICES

gh the emergency department is managed.
organization is addressed and managed in collaboration with organizational leaders, and with input from clients and families.
ken to prevent and manage overcrowding in the emergency department, in collaboration with organizational leaders, and with input from clients and
coordinated with other services and teams within the organization.

rgency department 24 hours a day, seven days a week.
ency department that impede clients, families, providers, and referring organizations from accessing services are identified and addressed, with input from
y services are provided in collaboration with partners.

f high-risk clients are established with Emergency Medical Service (EMS) providers.
d procedures are followed to coordinate timely inter-facility client transfers and transfers to other teams within the organization.
pleted with other health care services and includes information about referrals.
otocols to identify and manage overcrowding and surges in the emergency department.
elsewhere within the organization during times of overcrowding are followed by the team.
manage clients when access to inpatient beds is not available.
rcrowding and surges are followed before requesting aid from alternative health care sites or diverting ambulances.
es for current and potential clients, families, teams, and referring organizations is provided in a timely
nner.
ncy department are clearly marked and accessible.
the emergency department are evaluated.
Emergency Medical Services (EMS) and an initial assessment is conducted and documented by a nurse or other medical professional in a timely way.
n is transferred in collaboration with Emergency Medical Services (EMS).

hat are appropriate for pediatric clients are available and accessible.
ergency department are triaged in a timely way.

d to conduct the triage assessment.
pecific tool is used to conduct the triage assessment of pediatric clients.
ch client is completed and documented within established timelines, and in partnership with the client and family.
ch pediatric client is conducted within established timelines, and in partnership with the client and family.
mediate and urgent needs are identified and priorities of service are determined using set criteria, with input from the client's other service providers, and
and family.
ssment, clients who are waiting for service are advised which team member to contact if their condition changes.
cation with clients who are waiting for services.
rgency department are monitored for possible deterioration of condition and are reassessed as appropriate.
ies are partners in service delivery.

ent, and respectful relationship with each client.
couraged to be actively engaged in their care.
to be involved in their care is determined in partnership with the client and family.
ng family involvement in their care are respected and followed.
formation is shared with the client and family in a timely way, in accordance with the client's desire to be involved.
client and family understand information provided about their care.
tion services are available for clients and families as needed.
ivate and secure areas are available for clients.
ovide informed consent is determined.
sent is obtained and documented before providing services.
le of giving informed consent, consent is obtained from a substitute decision maker.
rovided with opportunities to be engaged in research activities that may be appropriate to their care.
proactively identified, managed, and addressed.
cess to manage medico-legal issues in the emergency department.
rovided with information about their rights and responsibilities.
rovided with information about how to file a complaint or report violations of their rights.
and respond to claims that clients' rights have been violated is developed and implemented with input from clients and families.
ent to the emergency department are effectively assessed.

psychosocial health is assessed and documented using a holistic approach, in partnership with the client and family.
designed with input from clients and families.
s of the client's care and services are identified in partnership with the client and family.
ools are used during the assessment process.
NAL PRACTICE:In partnership with clients, families, or caregivers (as appropriate), the medication reconciliation process is initiated for clients with a decision
ed on the receiving unit.
applicable to the setting, are identified and implemented to ensure a safe environment that prevents falls and reduces the risk of injuries from falling.
NAL PRACTICE:Clients are assessed and monitored for risk of suicide.

nd options for services are discussed as part of the assessment, in partnership with the client and family.
or pain management are discussed with the client.
nt's palliative and end-of-life care needs is completed, where appropriate, in partnership with the client and family.
tic services and laboratory testing and results is available 24 hours a day, 7 days a week.
s are used to select diagnostic imaging services for pediatric clients.
pharmacy staff can be accessed 24 hours a day, 7 days a week.
ation services is available 24 hours a day, 7 days a week.
specialists with expertise in pediatric health.
ommunicate and validate client diagnoses when there is discrepancy between the initial diagnosis and diagnostic imaging or laboratory results.
is reassessed in partnership with the client, and updates are documented in the client record, particularly when there is a change in health status.
ment are shared with the client and other team members in a timely and easy-to-understand way.
ividualized care plan is developed and documented in partnership with the client and family.
chieving goals and expected results is monitored in partnership with the client, and the information is used to adjust the care plan as necessary.
ons, including end of service, are identified in the care plan in partnership with the client and family.
nd tissue donors are identified and referred in a timely and effective manner.
tocols and policies on organ andmtissue donation.
ogical determination of death (NDD).
r potential organ donors to another level of care once they have been identified.
cal referral triggers to identify potential organ and tissue donors.
organ and tissue donation and the role of the organization and the emergency department is provided to the team.
how to support and provide information to families of potential organ and tissue donors is provided to the team, with input from clients and families.
r established for potential donors, the Organ Procurement Organization (OPO) or tissue centre is notified in a timely manner.
n process are recorded in the client record, including the family's decision about organ and tissue donation.
e care is provided to clients in the emergency department.

care plan is followed when services are provided.
e client, including changes and adjustments to the care plan, are documented in the client record.
during registration.
such as the use of armbands, is used to identify clients in the emergency department.
ponsibilities are adhered to during the resuscitation of clients.
NAL PRACTICE:Working in partnership with clients and families, at least two personspecific identifiers are used to confirm that clients receive the service or
consistently followed to provide the same standard of care in all settings to all clients.
uspected infectious diseases are identified, isolated, and managed.
ed sedatives or narcotics are monitored.
ced resuscitation equipment, supplies, and materials are available in the room where procedural sedation is administered.
c medication dosages is available and accessible to the team.
istered to pediatric clients using weight-based pediatric dosages and appropriately sized equipment.
ce and care is provided to meet clients' needs.
ve access to psychosocial and/or supportive care services, as required.
initiating palliative and end-of-life care, as required.
team members, and other clients is provided throughout and following the death of a client.
ATIONAL PRACTICE:Information relevant to the care of the client is communicated effectively during care transitions.
om Emergency Medical Services, triage, assessment, and admissions is transferred to service providers in the next setting.
ies are partners in planning and preparing for transition to another service or setting.
actively engaged in planning and preparing for transitions in care.
sed to determine whether a client is fit for transfer of care.
d psychosocial readiness for transition, including their capacity to self-manage their health, is assessed.
to self-manage conditions by receiving education, tools, and resources, where applicable.
ervices for the client, where applicable, are coordinated in collaboration with the client, family, other teams, and organizations.
cumented in the client record.
limit services, transfer to another service, or transition home, is respected.
mission is assessed, where applicable, and appropriate follow-up is coordinated.
nsitions is evaluated and the information is used to improve transition planning, with input from clients and families.
UALITY AND ACHIEVING POSITIVE OUTCOMES

s collected and used to guide quality improvement activities.
ectives regarding wait times, length of stay (LOS) in the emergency department, client diversion to other facilities, and number of clients who
e established, with input from clients and
ponse times are measured and used to set target times for clients brought to the emergency department by Emergency Medical Services.
services, the length of stay in the emergency department, and the number of clients who leave without being seen is tracked and benchmarked.
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INSTRUCTIONS: Work on a copy of this template.

AREAS FOR IMPROVEMENT

FUNCTIONING AS AN EFFECTIVE GOVERNING BODY

2.3 The governing body includes clients as members, where possible.

3.0 There is a defined and formal process for decision making.

DEVELOPING A CLEAR DIRECTION FOR THE ORGANIZATION

SUPPORTING THE ORGANIZATION TO ACHIEVE ITS MANDATE

7.2 The governing body follows a policy on CEO compensation.

8.1 A documented process is followed for granting privileges.

10.2 The governing body monitors organization-level measures of patient safety.

BEING ACCOUNTABLE AND ACHIEVING SUSTAINABLE RESULTS

AREAS FOR IMPROVEMENT

Infection Prevention and Control Standards

3.0 The organization collaborates with partners to promote IPC.

IMPLEMENTING THE IPC PROGRAM

6.0 Clients, families, and visitors are engaged in IPC practices.

7.0 The OHS program addresses organizational priorities for IPC.

7.7 Safety engineered devices for sharps are used.

8.0 A comprehensive hand-hygiene strategy is in place.

9.0 A clean and disinfected physical environment is maintained.

10.0, Manufacturers' instructions and accepted standards of practice are followed

EVALUATING THE IMPACT OF THE IPC PROGRAM

13.0 There is a coordinated approach for responding to outbreaks.

14.0 Ongoing improvements to the IPC Program are made.

ion and Control Standards

collaborates with partners to promote IPC.

cedures for loaned, shared, consigned, and leased medical devices.

and visitors are engaged in IPC practices.

m addresses organizational priorities for IPC.

cedures for using PPE that are appropriate to the task.

for sharps are used.

e hand-hygiene strategy is in place.

nteers have access to dedicated hand-washing sinks.

e results are shared with team members and volunteers.

nfected physical environment is maintained.

are assigned for cleaning and disinfecting the physical

instructions and accepted standards of practice are followed

s and equipment are cleaned before disinfection or sterilization is done.

devices are prepared for sterilization according to manufacturers' instructions.

ions are followed to pre-clean flexible endoscopes immediately at point of use.

re stored in a manner that minimizes contamination and damage.

E IMPACT OF THE IPC PROGRAM

promptly detect suspected health care-associated infections in the organization.

dinated approach for responding to outbreaks.

vements to the IPC Program are made.

are shared with team members, volunteers, clients, and families.

Dept.: Quality Department

AREAS FOR IMPROVEMENT

CREATING AND SUSTAINING A CARING CULTURE Score

2.8 Continuing professional development and learning is supported.

3.0 A quality improvement culture is promoted throughout the organization.

PLANNING AND DESIGNING SERVICES

4.2 The organization has a vision and strategic plan.

6.5 Formal strategies or processes are used to manage change.

7.0, The organization's leaders collaborate with a broad network of stakeholders.

ALLOCATING RESOURCES AND BUILDING INFRASTRUCTURE

9.0 The physical environment is safe.

10.2 Retention strategies are implemented.

10.6 Reporting relationships are defined for all team members.

10.10 Reporting relationships and leaders' span of control is regularly evaluated.

11.0, Information management policies and systems meet current information