Accreditation Countdown

In just two days, Accreditation Canada Surveyors will be on site, and they will visit the BC Cancer Agency’s regional centres from May 31 to June 4.

This accreditation process is different than in the past, as Surveyors will be engaging more frequently with front-line staff to ensure compliance with the 28 required organizational practices (ROPS). Surveyors will be using a “tracer” method – where they, accompanied by a staff person, will “trace” the path of a patient or an administrative process to gather evidence about an organization’s quality and safety practices.

“Being able to provide adequate documentation that you are engaging in a quality and safety process is absolutely necessary, but that’s just the starting point. For the new Accreditation process, Surveyors will look for evidence that such policies and processes are understood and being fully implemented by staff,” says Sue Fuller-Blamey, director of Quality & Safety and Accreditation.

Accreditation Survey: the Sequel

Thank you to the more than 400 staff who completed our follow-up Accreditation Survey.  See the correct answers, and to find out more about Accreditation, visit the h:drive at H:\everyone\Accreditation 2009.

Congratulations to Irma Vulto, Research Centre, and Ellen Suarez, Volunteer Services, Fraser Valley Centre – winners of the Cactus Club Gift Certificates.
“Surveyors will be a lot more hands-on and visible than they have been previously. One Surveyor will be dedicated to each site, and will spend the majority of his or her time observing or tracing processes on the front-line.”

“They may follow a patient through their visit at a centre,” continues Sue, “They may ask to speak to a physician or nurse after a consultation to ensure the proper documentation, such as an allergy form, has been completed, and speak with a patient to confirm their understanding of their treatment plan and options."

In addition to the in-depth tracer method, Surveyors will be asking staff at random questions about the required organizational practices – such as “do you ask patients for two identifiers before treatment?” and “do you practice regular hand hygiene?”

Surveyors will also be reviewing charts at random to ensure the proper documentation is recorded, and they may come back a day or two later to observe that staff are indeed following the required organizational practices.

For example, Surveyors may ask staff about their hand washing practices, and may come back the next day and observe whether the recommended guidelines are being followed during a busy clinic.

Staff from throughout the Agency have worked hard to prepare for the Surveyors' visit. “The Accreditation process has given us an opportunity to review, teach and learn,” says Sandra Broughton, regional operations leader, Centre for the Southern Interior. “Staff have been involved in team education, centre-wide education activities, and ongoing discussions with their managers and leaders.

“We will learn from this process, and we will continue to focus on improving both patient and staff safety and quality throughout the organization.”

Everyone is invited to hear from the Surveyors on Thursday, June 4 from 11 a.m. to noon at a debriefing session to be held in Vancouver at the BC Cancer Agency’s Gordon and Leslie Diamond Lecture Theatre and videolinked to:

FVC Main Floor Conference Room
VIC Meeting Room #3, Room 3202
CSI Okanagan Room
AC Clinical Conference Room

Meet your Surveyors

Surveyor, Abbotsford Centre
Bertha Paulse

During her career, Bertha has held a number of senior level positions including chief executive officer of the Newfoundland Cancer Treatment and Research Foundation; chief operating officer at London Regional Cancer Centre in London, Ontario; and assistant executive director, Medical Support Services at the Salvation Army Grace General Hospital in St. John’s, Newfoundland.

Bertha has a M.H.S.A from Dalhousie University in Halifax, Nova Scotia, and a bachelor in nursing from Memorial University in St. John’s, Newfoundland.


Surveyor, Fraser Valley Centre
Dr. James Gilchrist

Dr. James Gilchrist has been working for Cancer Care Ontario starting with the London Regional Cancer Centre in 1971 as a radiation oncologist. He has a particular interest in head and neck, gynecological and skin cancers.

Jim obtained his medical school training from the University of London, UK, and obtained his degree in medicine in 1965.


Surveyor, Vancouver Centre
Juanita Barrett 

Throughout her career, Juanita has held a number of senior positions, including team leader of Primary Health Care for the Newfoundland Department of Health and Community Services; vp, Peninsula Health Care Corporation; patient services director, Riverview Hospital; and patient services director, Terrace and Area Health Council.

She holds a masters of business administration degree and is a registered nurse. Juanita has worked with health and government agencies in reorganizing/restructuring, program management, regionalization, planning, change management and developing quality improvement processes.


Surveyor, Vancouver Centre
Nancy Guebert

Nancy’s previous appointments within the Calgary Health Region have included vice-president, Emergency and Unscheduled Access to Services; executive director, Medical Services; director of Surgical Inpatients and Trauma Services; and manager of Tertiary Palliative Care and Acute Oncology. Prior to Nancy’s relocation to Calgary, she was the executive director of Education and Corporate Affairs for the Saskatchewan Cancer Agency.

Nancy holds a bachelor of Science in Nursing with great distinction and a Masters in Continuing Education from the University of Saskatchewan. Nancy is past-president of the Canadian Association of Nurses in Oncology and presently the president of the Southern Alberta Chapter of the Canadian College of Health Services Executives.


Surveyor, Vancouver Island Centre
Dr. Eshwar Kumar

In addition to his role with the Atlantic Health Sciences Corporation, Dr. Kumar is the co-CEO of the New Brunswick Cancer Network which was formed to oversee the planning and delivery of cancer services in New Brunswick.

A graduate of St. Johns Medical College at Bangalore University, India, he obtained his fellowship in radiotherapy and oncology from the Royal College of Radiologists, London, United Kingdon, in 1982. He has a special interest in the management of breast, gynecological and GU cancers. Dr. Kumar is on the board of directors of the Canadian Association of Provincial Cancer Agencies (CAPCA). He represented New Brunswick on the council for the Canadian Strategy for Cancer Control (CSCC).


Surveyor, Centre for the Southern Interior
Natalie Bubela

Prior to joining Rouge Valley Health Systems in 2000, Natalie held a number of senior positions in a variety of patient care areas including complex continuing care and specialized geriatrics and rehabilitation services; cancer care; and paediatrics. Before moving to management, Natalie was a clinical nurse specialist in cancer care at Sunnybrook Health Sciences Centre and also on staff at the University of Toronto, Faculty of Nursing.

Natalie holds a bachelor of science in nursing from Queen’s University in Kingston and a master of science applied degree from McGill University in Montreal. She is a member of the Canadian College of Health Services Executives.


Advancing Strategic Direction #1
Sustain and advance the BC Cancer Agency's system of cancer control.

Do you know your emergency colours?

Most staff know that Code Blue indicates there’s a patient in medical distress requiring immediate attention, or that Code Red is called when fire or smoke are detected.

But what about a Code White (for aggressive behaviour) or Code Silver (for systems or utility failure)?

As part of effectively managing any emergency or crisis, all staff need to be aware of what action to take once they hear a code. Knowing your emergency codes is also a required organizational practice for Accreditation.

“A public address system is the quickest and easiest way we have to get the information out in the event of an emergency,” says Robin Gardner, PHSA Emergency Management Services. “But the system only works if all staff are aware of what each code means and what action to take. Hesitating even a few moments if you hear a code green or code black could have a negative impact.”

PHSA Emergency Management, with input from Agency staff has developed a quick reference sheet for the codes, which includes locals to call, whose responsibility it is to respond, and what you need to do when a code is called. (CSI staff will continue to refer to their handy desk-top booklet).

As part of effectively managing any emergency or crisis, all staff need to be aware of what action or steps to take once they hear a code. Knowing your emergency codes is also a required organizational practice for Accreditation.
The new one page sheet is now being posted on bulletin boards by administration staff for quick reference, so you don’t have to go searching for a booklet, or flip through several pages to find a number. Most staff will have also already received a handy little card identifying the codes to attach to their lanyards. If you require additional posters or lanyards, please contact your administration office.

In the event of an emergency, staff at the Centre for the Southern Interior, Vancouver Island, and Fraser Valley and Abbotsford Centres will call their health authorities with whom they’ve contracted out services. However, all staff – regardless of their site – should know their codes, and have the numbers within easy reach in the event of an emergency.

If you have any questions about the emergency codes or emergency preparedness, please contact Robin Gardner at rgardner@phsa.ca

Patient Safety Plan

Patient safety is at the heart of Accreditation – and as a cancer care organization, it is our highest priority.

The focus of our policies and guidelines – such as using two patient identifiers, proper hand hygiene, and reconciling medications – is to ensure the safety and health of our patients. However, sometimes mistakes can occur, and there may be room for improvement in existing practices. Research shows that patient safety can dramatically improve within an organization, if there is a Culture of Safety supported by top leaders, and a commitment to tackling the root causes of a problem, rather than blaming individuals for errors.

“We know that staff are committed to providing a safe environment for patients,” says Sue Fuller-Blamey, director of Quality and Safety at the BC Cancer Agency. “Our Patient Safety Plan will further help support their efforts, and provide staff with the tools to further reduce potential risk.”

The BC Cancer Agency’s Patient Safety Plan has identified the following key strategies to improve patient safety:
• Demonstrate executive level commitment to patient safety
• Identify patient safety priorities and strategies
• Track and trend adverse events (through Patient Safety Learning System)
• Provide education and professional development for staff

Departments are encouraged to add safety as an agenda item at regular meetings, and discuss safety issues often. “The research shows that if staff feel comfortable talking about patient safety issues and near misses with each other and their leaders, the number of real incidences decreases,” says Sue.

Two new brochures have been produced and are currently being distributed to staff and patients. The Patient Safety Handbook for Healthcare Providers which looks at ways to minimize safety risks, and 20 Tips to Help you be Part of the HealthCare Team: Patient Safety is #1 for patients and their families.

“Patients can contribute enormously to ensuring safety,” says Fiona Bees, leader of the Agency’s Quality Council, Chief Nurse, and associate vice-president, Cancer Care. “Staff should welcome questions that patients may have about their care, as ultimately that increases the safety and quality of the care provided.”

As an organization, the Agency is contributing to research on patient safety. The Agency is part of a Canadian group of cancer agencies looking into establishing national standards – such as criteria for pump selection and education required for patients – when infusional chemotherapy is carried out at home. “The Agency can play a leadership role in improving patient safety for cancer patients in B.C. and the country,” says Fiona.

Advancing Strategic Direction #1
Sustain and advance the BC Cancer Agency's system of cancer control.

Study identifies protein that makes breast cancer cells more invasive:
Understanding cell behaviour may offer new treatment targets

BC Cancer Agency scientists, in collaboration with international researchers, have identified the important role that a specific protein plays in breast cancer metastasis (spread of cancer cells to distant tissues or organs in the body), which may lead to new treatment targets in the future.

Published this May in the journal Cancer Cell, the study found that high amounts of a protein called YB-I (Y-box binding protein-1), which is present in a subset of breast cancers, causes two different reactions in tumour cells. YB-1 actually slows or stops the growth of cancer cells at the primary site. However, it simultaneously enables these cells to become more invasive and to migrate to secondary sites, thereby potentially causing a recurrence of breast cancer when the cells re-activate.

“It’s disturbing that approximately 30 percent of breast cancer patients may develop metastatic disease, and that this may occur five to 10 years after their initial treatment,” says Dr. Poul Sorensen, principal investigator of the study, a senior scientist at BC Cancer Agency, and the Johal Chair in the Childhood Cancer Research Program at the Child & Family Research Institute at BC Children’s Hospital. “It’s unclear why this happens, but scientists have hypothesized that certain drug-resistant cells persist after treatment and resume growth after being dormant for extended periods.”

“Our study has now identified that the YB-I protein ‘reprograms’ certain breast cancer cells to become dormant and to gain the ability to crawl out of the primary tumour site to other parts of the body, potentially giving rise to metastatic disease.”

For the full story, please go to: www.bccancer.bc.ca/ABCCA/NewsCentre/2009/yb1.htm  

Advancing Strategic Direction #2
Establish the knowledge generation and application model within the provincial cancer control platform.

Uncovering a familiar face

BC Cancer Agency and Foundation staff in Vancouver recognize Caitlin Clugston as the first face we see when we walk into the Agency’s Research Centre. But what you might not know is that Caitlin is also a cancer survivor, having fought colon cancer just four years ago.

Caitlin decided to celebrate her good health this year by walking in the BC Cancer Foundation’s The Underwear Affair on July 11th.

“I’ve looked at the brochures every year and thought it would be fun idea to get a group together to walk or run - so this is the year,” she says.

Asked why she thinks it’s important, Caitlin says: “It’s important to represent the young faces of cancer. The cancers addressed by The Underwear Affair are those that people aren’t as willing to talk about and I think bringing some awareness to these cancers is really important. As a survivor, being a part of something that is going to bring about improvements in research, care and prevention feels great.”

So to those who might be considering taking part in BC Cancer Foundation’s
The Underwear Affair, Caitlin says: “Go out and do it! I think people often hesitate because they feel their contribution would be so small it won’t make a difference. But that is simply untrue. Action is going to get the results.

"And besides, have you seen what people wear to this thing?” she laughs. “The sheer spectacle alone is worth turning up for! I know my team is busy searching for some bloomers.”

Get more information, support Caitlin or join your Agency colleagues on Team BC Cancer for BC Cancer Foundation’s The Underwear Affair (5km walk/10km run), on July 11th, 2009, at www.uncoverthecure.org or at 604.734.CURE (2873). 

And don’t forget… there is still time to register for The Ride to Conquer Cancer. There are 11 BC Cancer Agency teams riding! www.conquercancer.ca

Team BC Cancer also has some exciting events planned for the bigger, better Weekend to End Breast Cancer on August 15 and 16th – check it out at www.endcancer.ca.  

Contact the BC Cancer Foundation:

Provincial Office:
604.877.6040
infobccf@bccancer.bc.ca  

Abbotsford:
Liz Harris
604.851.4736
lharris3@bccancer.bc.ca  

Fraser Valley:
Kate Ludlam
604.930.4083
kludlam@bccancer.bc.ca  

Southern Interior:
Cynthia Waldek-Peters
250.712.3910
cwaldekpeters@bccancer.bc.ca  

Vancouver Island:
Laura Walsh
250.519.5554
lwalsh@bccancer.bc.ca  

Vancouver:
Sharon Kennedy
604.877.6040
skennedy@bccancer.bc.ca  


Advancing Strategic Direction #4
Ensure we have the resources to achieve maximal organizational effectiveness.