SECTION 2
Client Care and Service
Community Focused
Continuing Care
Emergency/Trauma
Maternal, Child & Youth
Medical Care
Mental Health
Palliative Care
Specialized Intensive Care
Surgical Care

SECTION 3
Support Services
Information Management
Human Resources
Physical Environment

SECTION 4
Leadership/Partnership
Strategic Directions
Implementing Strategic Directions

F O R E W O R D

On January 16th, 2001, Mr. Bruce Harber, Chief Executive Officer,  North Shore Health Region, presented the results of the 2000 accreditation report of our September 17 - 22, 2000 survey.

Inglewood Care Centre participated in the accreditation survey, and the Board of Directors of the Canadian Council on Health  Services Accreditation is pleased to advise that Inglewood Care Centre has been granted ACCREDITATION WITHOUT RECOMMENDATION.

Inglewood Care Centre's Vision, to become a Centre of Excellence, to be the First Choice in Continuing Care has been achieved with this results. The Staff, at Inglewood know, that we will work hard to uphold this honor, and to ensure that we will continue to be The First Choice in Continuing Care. 

SUMMARY

The North Shore Health Region (NSHR) is congratulated on its commitment to monitoring and improving the quality of care and services provided. All sites and services identified as participants are commended on preparing for the organization's first system wide accreditation survey. Inglewood Lodge and Private Hospital (Inglewood Care Centre),  is recognized for participating as an affiliate organization. The process includes voluntary self-assessment and peer review, team and client interviews, review of pertinent documentation and site visits.

Client feedback was generally positive regarding all aspects of care and service. Staff and physician feedback revealed positive support for program management, leadership by senior management, and the overall approach to rationalization and integration of care and service.

There is evidence of good partnerships with community services, affiliate organizations and government agencies. These relationships together with other informal links to community resources are strengthening referral networks within the region. Site tours revealed generally well maintained buildings, some space and safety issues at Lions Gate Hospital, and less than adequate signage at Parkgate Community Health Centre. 

Over the last two years there has been a positive shift in physician relations at the senior level and the board and executive management team are commended on their efforts. Encouragement is offered to continue efforts in this regard. They have also established an excellent framework for quality improvement which now requires organization-wide implementation. The board needs to approve an ethics process and a risk management reporting process to ensure itself that ethics issues, risk and quality are in hand and well managed. Risk issues were identified and relate to fire drills and evacuation exercises, and processes for obtaining proper consent from clients of maternal services, specifically for any invasive procedures.

It is hoped that through the accreditation experience and the enclosed report, teams will be assisted with their quality improvement efforts. By addressing the recommendations and considering the suggestions contained in the report, the NSHR will increase its compliance with national health system accreditation standards.