Learning from Experience: Ensuring Canadians with SCI Receive Equitable Care Through Accreditation

Focusing on the patient and family experience key to Hamilton’s Regional Rehabilitation Centre’s successful re-accreditation

The SCI Accreditation Standards are a comprehensive set of evidence-based guidelines that enable health care providers to provide consistent and optimized care for anyone entering an acute or rehabilitation hospital after sustaining a spinal cord injury. The Standards were originally developed in 2012 in partnership with Accreditation Canada and Praxis Spinal Cord Institute. Over the years, Praxis has worked with its network of Rick Hansen SCI Registry-affiliated hospitals to support these hospitals in obtaining accreditation status. Hamilton Health Sciences Regional Rehabilitation Centre (RRC) is one such facility who recently re-accredited to maintain their status in June 2019, passing with “Exemplary Standing”.

We spoke to Mirela Anton, RN, one of the leads on the accreditation team at RRC to learn more about what the team did differently this time around.

How long have you worked at Hamilton Health Sciences Regional Rehabilitation Centre (RRC)?

I’ve been working in the rehabilitation team for almost 12 years, but have a total of 22 years in the organization! I am a nurse clinician, currently work across many different areas of our rehabilitation facility including the SCI and Amputee Rehabilitation programs – I certainly wear many different hats!

What was your role during your facility’s accreditation process?

I was part of the leadership team but also worked as a front-line member of staff. We established a leadership team with representatives from the different rehabilitation programs. We also had representation at a corporate level.

You were part of RRC’s accreditation team when it first accredited four years ago. Did you find having prior experience helpful?

Not necessarily, since every experience is different! Each time you are part of an accreditation process you learn something new. This time around, it directed us to be [even more] patient- and family-focused and, I would say, this was one of our biggest successes. You think you’re already involving patients and their families but when you get down to it, you may be missing things you didn’t even realize. You can always do a better job!

What initiatives did you put in place to help with being more patient/family-focused?

We have a Continuous Quality Improvement (CQI) management system in our rehabilitation program. Through the CQI process we were able to empower and directly engage our patients and families to provide feedback on what we are doing well and on what we can do better. We track patient and family engagement on a monthly basis and we meet with the team every morning at the CQI Huddle, to help move opportunities for improvement forward. It helps us look at our standard process in order to improve quality of care for patients. Accreditation Canada gave us really good feedback on this.

RRC is known for its comprehensive clinical expertise in respiratory management.

 

What did you find most challenging about the process? How did you overcome this?

The most challenging thing was having enough time. It is important to get everyone organized, particularly at the beginning of the process by creating a leadership team. Once the team was established things got easier. It’s very important to have a good team leading the process!

You also need to look at ways to improve, as ultimately you are doing this to better understand how you can do things better. We found doing the self-assessment survey and involving the wider team outside leadership helpful with this. It’s ok to not be perfect; feedback should be seen as a good thing. You are doing a great job but how can you do an even better job? I personally like accreditation, I find it enlightening!

What was your biggest success?

Our biggest success was that we worked well as a team. This accomplishment couldn’t have happened without the efforts of every member of our team that took to prepare and participate in the accreditation process. Thanks to their hard work we were able to convey to the accreditation team the compassion, knowledge and skill and the dedication that we have for our patients.

What would be your best tip for another facility preparing to go through accreditation?

1. Stay patient- and family-focused! Get as much input from them as possible and incorporate it into your practice. It is important to give patients and families a medium for them to relay their thoughts, ideas or suggestions.
2. Maintain good communication between all those involved. Having a leadership team in place really helps set the stage for the ongoing process. Continue to have meetings at both the program and corporate level. Importantly, our big focus post accreditation is to maintain all the initiatives that we put in place.
3. Learn from one another! Understand how to make better use of your current processes in order to enhance quality and safety. Implement new initiatives and learn to celebrate all the successes and the great work that goes on within the program.

Mirela Anton, RN is a Nurse Clinician at Hamilton Health Sciences Regional Rehabilitation Centre.

Have questions about the accreditation process? Contact clinical@praxisinstitute.org.