North York General completes first hybrid, virtual and on-site accreditation survey

December 17, 2020

The accreditation process is “extremely important,” even during the COVID-19 pandemic, says Sean Molloy, Director of Patient and Family Centered Care and Care Transitions at North York General Hospital in Ontario.

Sean Molloy, Director of Patient and Family Centered Care and Care Transitions

“It’s extremely important that organizations continue their accreditation process, as the standards are integral to patient safety, quality and patient- and family-centred care,” Molloy says. “The pandemic has changed what we need to do every day, but it hasn’t changed the fact that we need to deliver care in a safe way.”

North York General completed a hybrid, virtual and on-site accreditation survey in late October, after its original survey date was postponed from March due to the COVID-19 pandemic. “We’ve gone through two waves of accreditation readiness during a pandemic,” Molloy says.

North York General is one of Canada’s leading community academic hospitals, spanning across seven sites, offering 435 inpatient beds and 192 long-term care beds. Since the beginning of the pandemic, Molloy notes that the organization has seen “in the thousands” of positive COVID-19 cases.

Molloy says the organization was happy to be able to complete its accreditation survey despite the ongoing pandemic situation. “I think it went very well. Staff members, physicians, leadership, learners, our board members and patient advisors were all very happy that we were able to do it,” he says. “I think everyone felt that it was very important to get it done even in the middle of the pandemic, because it speaks to our processes related to quality and patient- and family-centred care.” He adds that it was an opportunity for teams to “put their best foot forward” and showcase the great work they’ve been doing during a particularly challenging time.

Stephanie Robinson, Manager, Quality and Service Innovation

Stephanie Robinson, Manager, Quality and Service Innovation at North York General notes that though evaluations for standards related to items such as Governance and Leadership were done virtually, Accreditation Canada (AC) surveyors were physically on site for the week. To maintain safety and physical distancing, the priority process interviews, meeting with board members and the final report out were carried out using virtual platforms while the organization also had to prepare for the arrival of the survey team.

Robinson says surveyors were provided with personal protective equipment (PPE) and were also trained on how to use that equipment safely. “We followed each department’s guidelines for infection prevention and control to ensure surveyors were protected and it was safe for them to see what’s going on in the hospital,” she says. “Because they were coming from other organizations outside of the city, there was some concern about coming to a Toronto hospital because of the number of cases in the GTA community.”

Molloy says the new hybrid, virtual and on-site survey model – born out of COVID-19 – “worked well” for North York General. “It needs to be highly facilitated, organized and planned but moving forward, we would have no hesitancy in doing it again.” Robinson adds that the hybrid survey was a positive experience as it allowed more people to connect without everyone having to be in the same room. “We would definitely continue,” she said. “That’s one of the benefits of the pandemic requiring our hospitals to rapidly become more virtual. It’s been wonderful to connect with people wherever they are.”

Anita Harris, a surveyor on the North York General survey, says she wondered if the organization would still be motivated for the October survey, as it had already fully prepared for its March survey, which was postponed only a few days before it was set to begin. “But my query was answered just moments into the survey,” says Harris. “The teams in the survey areas we visited were so eager to speak with surveyors and show off all the good work that was being done. They were very proud of their hospital, their team and the work they were doing for their entire community.”

Harris adds the survey pivoted to a hybrid, virtual and on-site model only days before surveyors were due to arrive at North York General. “This was accomplished seamlessly, due to the masterful preparations done by the hospital,” she says. “They thought of everything, in order for the survey to be completed safely, effectively and successfully.”

Molloy notes the accreditation process is valuable at any time, as it is an external peer review that ensures you are keeping up to date with set, nationally agreed upon standards for patient safety and quality of care. “During a pandemic, I think [accreditation] is invaluable,” he says. “So much has changed so rapidly and organizations that have the ability to maintain standards in crisis are high-functioning organizations.”

He adds North York General did not question completing its accreditation process in the middle of the pandemic. Molloy says the organization embraced it as “a meaningful challenge.” “It’s important to have standards in place because no matter what you’re doing, you’re ensuring that you’re doing it safely,” he says. “We’re very proud of the length we’ve gone to, to continue to engage patients and families during the pandemic, because that has been challenging but essential to maintaining patient and family input into how we deliver services.”

Robinson notes that to address hospital visitation during the pandemic, North York General established the Virtual Family Visits Program, which enables patients to have social interactions with loved ones through iPads. “We know there is a lot of social isolation for patients and that family members and caregivers are an integral part of care,” she says. “We had to figure out a way to facilitate virtual connections between patients and family members.”

Robinson says the program has enabled connections with family members who live far away. “People were calling in from England, from the United States. It enabled visits with family members who normally, would probably not be able to fly in to visit their loved one in the hospital,” she says. “Now, they are able to have a conversation.” She adds the pandemic has made it necessary for health organizations to find ways to be virtual. “This is a program we are very proud of,” she says.

Robinson says the accreditation process is a good learning opportunity for the organization, as it requires everyone to gain knowledge about standards, Required Organizational Practices (ROPs) and more. “It’s an excellent opportunity to learn, to teach and to identify gaps in your processes, which helps with quality improvement,” she says.

Robinson adds that she’s been moved by the work North York General has been able to accomplish despite the ongoing pandemic. “The pandemic has really shown me how well our teams are able to work together to find solutions that will meet the needs of our community,” she says. “There’s burnout for everyone, but I still see people coming to work with new ideas and positivity.”