Report No. 030-12

TO: Chair and Members of the Board of Health
FROM: Graham L. Pollett, MD, FRCPC, Medical Officer of Health
DATE: 2012 February 16

Results of the 2011 Accreditation Follow Up Site Visit

Recommendation

It is recommended that Report No. 030-12 re Results of the 2011 Accreditation Follow Up Site Visit be received for information. 

Background

Board members will recall that the Health Unit underwent a comprehensive Accreditation review by the Ontario Council on Community Health Accreditation (OCCHA) in September 2010. The outcome of this process was the awarding of an Unconditional Accreditation designation for three years, representing the highest award issued by OCCHA.

In contrast to previous accreditation surveys, OCCHA modified its accreditation process to include two annual follow up site visits and organizational questionnaires. The 2011 site visit was on September 30, and the results were received January 18, 2012. This report highlights the results of that visit.

Results

The Health Unit successfully maintained Unconditional Accreditation status and received positive feedback on each of the 18 featured projects from Health Unit programs. The OCCHA report noted the Health Unit’s successful completion of the 2010 required follow-up items and indicated that no further follow-up was required. In preparation for the 2012 site visit, the OCCHA report recommends the Health Unit continue progress on five items:

1.   Implementation of the Board of Health strategic directions.
2.   Development of strategies and/or tools to enhance the process of communicating changes to the individual position descriptions.
3.   Ensuring that performance evaluations are being conducted in a manner consistent with agency policy.
4.   Streamline policies and procedures and ensure a consistent approach to review across all program areas.
5.   Implementation of the new planning template across all service areas, including documentation of actual achievements/outcomes. 

The report indicated that OCCHA surveyors will also look for maintenance of three items at the 2012 site visit:

1.   Confirmation that the Health Unit’s “committee policy” includes all new committees and has removed any disbanded committees.
2.   Confirmation that monthly Occupational Health and Safety inspections are conducted for all offices.
3.   Confirmation that Services Areas Workplace Hazardous Material Information Sheets (WHMIS) inventories are current and that re-training for all staff has been completed in a manner consistent with agency policy/practice. 

Next Steps

The Health Unit’s Continuous Quality Improvement Committee is currently developing strategies to address the identified items as part of preparation for the 2012 site visit. This visit is expected to occur in late September.

This report was prepared by Mr. Ross Graham, Manager, Special Projects.

Graham L. Pollett, MD, FRCPC
Medical Officer of Health

This report addresses Accreditation at the Middlesex-London Health Unit.