Post on 03-Aug-2020
Accreditation Report Quality Improvement Plan & Benchmarking Data
Prepared for St. Joseph’s Villa of Sudbury
Three-Year AccreditationThree-Year Accreditation
Accreditation Decision
Three-Year Accreditation Expiration: November 30, 2018
Organization
St. Joseph’s Villa of Sudbury (SJV) 1250 South Bay Road Sudbury ON P3E 6L9 CANADA
Organizational Leadership
Jo-Anne Palkovits, Administrator
Survey Dates
October 29-30, 2015
Survey Team
Avanthi Goddard, BBA Hon., Dip Adult Ed., Administrative Surveyor Bruce Hartshorne, CASP, Program Surveyor
Programs/Services Surveyed
Person-Centred Long-Term Care Community Governance Standards Applied
Previous Survey
November 1-2, 2012 Three-Year Accreditation
Survey Summary
Areas of Strength
St. Joseph’s Villa of Sudbury (SJV) has strengths in many areas.
The person-centred philosophy is led, embedded, and implemented through the mission and values of the organization that has a strong and long spiritual history.
The volunteer program has gone from 35 volunteers to approximately 120 volunteers in less than three years. The effective strategies of engaging the community; the strong reputation in the city and region of the program and its parent organization; and the family-like, respectful, and engaging work environment have contributed to the success of volunteer recruitment and retention.
The board of directors implements a framework of governance that is well supported by its by-laws and extensive policies, and demonstrates an effective governance model that leads and is passionate about the mission, values, and vision.
The staff members at the organization have a strong team culture that is supportive of each other and person focused. This is evidenced by the positive energy and innovative ways of engaging persons served daily in “having fun,” “enjoying coming to work,” and feeling appreciated even through a difficult workload and financial challenges.
There are many examples of quality improvement initiatives that demonstrate effectiveness and efficiency of both the business processes and improving the living experience, safety, and outcomes of persons served. These include, but are not limited to, the improved safety strategies for a growing population with dementia, improved clinical scores for wound management, falls, incontinence, and building and space utilization. Peer evaluation and auditing techniques have been used to ensure that quality standards are being met.
It is evident that the management seeks to hire highly motivated and qualified employees and then encourages them to use their skills and creativity to come up with solutions for effectiveness, efficiency, and business function. The staff members have responded well to the encouragement by providing many new initiatives in the areas of supplies savings, work order control, cost and control accounting, etc.
Infection control practices are very diligent as evidenced by the fact that the home has managed to have only one outbreak in the past year that closed the program to visitors for only a short duration.
Innovative and leading-edge programs and frameworks have been implemented that have and will continue to create quality improvements. In addition, the Quality Framework and its mapping from operations to strategic direction is a unique system of supporting the achievement of quality goals and targets through the use of an accountability framework of committees that is linked from operational committees to committees of the board of directors who are accountable for the mission and vision of the organization. The organization has been recognized for this unique system by Health Quality Ontario; was asked to present at the Health Quality Transformation 2013 conference; and was visited by the Minister of Health and Long-Term Care, Ontario, to acknowledge the innovative way the organization has engaged the board and its managers in being accountable for quality improvement and achieving its targets.
St. Joseph's Villa of Sudbury Accreditation Report 1
Areas for Improvement
SJV should seek improvement in the following areas.
The emergency plan does not identify essential services and the continuation of essential services. The organization is urged to update written emergency procedures to address the identification and the continuation of essential services.
Only evacuation and fire procedures have been tested annually on all shifts. The organization is urged to conduct unannounced tests of all emergency procedures on each shift. Tests should be analyzed for performance that addresses areas needing improvement, actions to be taken, results of performance improvement plans, and necessary education and training of personnel, and should be evidenced in writing.
The organization uses analysis of each incident to identify corrective and preventative action, but does not trend critical incidents over a long enough time period to identify trends and is therefore urged to address trends in its annual written analysis of all critical incidents.
The program should review its scope of services at least annually to ensure that capacity and competency of the organization are able to meet the changing and complex needs of the persons served.
Although the organization was able to verbalize how refunds are to be handled, the person’s written agreement did not reflect the practice. The person’s written agreement should contain information regarding the refund policies.
The program’s written philosophy of health and wellness should address aging in place. Although the effectiveness of education is reviewed and educational plans and content are changed as
needed, performance targets have not been established. The organization should measure the effectiveness of the learning techniques used in the learning environment for personnel against a performance target.
The organization should provide documented competency-based training for personnel at orientation and at regular intervals that includes the gathering of information about the person’s history, current status, important memories, favourite stories, daily routines, comfort/reminiscence objects, and people of importance.
Although the organization has a policy that addresses visiting hours and this information is included in the handbook for persons served, the policy indicates that visiting 24/7 is only by exception. The organization should develop policies and written procedures that allow the opportunity for the persons served to receive visitors 24 hours a day, if desired and the visit does not infringe upon the health, safety, or rights of any persons served and not just by exception.
2 St. Joseph's Villa of Sudbury Accreditation Report
Accreditation Decision
St. Joseph’s Villa of Sudbury has earned a Three-Year Accreditation. On balance, SJV has demonstrated substantial conformance to the CARF standards and has used the standards to improve effectively over time. The organization has a well-informed leadership team that implements best practices and leads the industry in the region with cutting-edge and innovative ways of being effective and efficient to its mission. The organization has a culture of quality improvements at all levels. The organization appears to have the commitment and resources to address the opportunities for improvement noted in this report and is encouraged to continue to use the CARF standards to further enhance the provision of its services.
St. Joseph's Villa of Sudbury Accreditation Report 3
Consultation
Section 1. ASPIRE to Excellence®
A. Leadership The leadership is encouraged to expand its assessment and learning of the organization’s cultural
competency and diversity gaps that demonstrate its awareness of the diversity of the key stakeholders. The organization has some written procedures on how to deal with allegations of violations of ethical
codes in documents, such as union contracts and board by-laws. These procedures do not relate to the ethical codes directly and the procedure is not easily accessed should a violation occur. The organization may want to include the violation procedure with the code of ethics and conduct documents.
E. Legal Requirements The staff and volunteer paper format files are maintained in file folders. The sections are divided by
loose sheets of paper and the documents are loosely filed and not secured, with a potential of being lost or missed during a review process. The organization may want to consider a way to secure the paper through mechanisms such as clips or fasteners to ensure the security of the paper files.
J. Technology The organization may want to include the disaster recovery preparedness plan with the emergency
manual to ensure consistency in direction and ease of access for leading the implementation of the emergency plan.
Consultation does not indicate non-conformance to standards but is offered as a suggestion for further quality improvement.
4 St. Joseph's Villa of Sudbury Accreditation Report
Standards Conformance This section of the Accreditation Report displays the specific reasons for any partial or non-conformance to standards identified as a result of the survey. The standards listed in this section are addressed in the organization’s Quality Improvement Plan, which can be accessed at customerconnect.carf.org.
Below are the possible reasons for partial or non-conformance to standards, along with an explanation of why each reason is cited.
To receive the information contained in this section in an alternate format, please contact editing@carf.org.
Reason for partial or non-conformance Is cited:
Credentials inadequate When a standard element requires that an individual possess a specific credential or level of credential, the specific credential is not possessed, or the credential possessed is below the specified level.
Data or information necessary to address conformance not collected and/or evaluated
When the issue addressed by the standard element has not been considered and, consequently, the information necessary to address conformance has not been collected and/or evaluated in connection with the issue addressed.
Documentation inadequate When a standard element requires documentation or that documentation contain specific information, the documentation either does not exist or does not contain the specific information.
Effort not comprehensive When a standard element requires an activity to occur, the performance of the activity is insufficient to address the full scope of the activity.
Financial ratio calculation below the median
When the standard element rating is based on the calculation of a specific financial ratio, such ratio is below the 50th percentile.
Forms inadequate When a standard element requires use of a specific form or that the form contain specific information, the form is not used or does not contain the specific information.
Frequency inadequate When a standard element requires that an activity occur with a specific frequency or some unspecified regularity, the performance of the activity does not occur, occurs less frequently than required, or occurs less frequently than appropriate if regularity unspecified.
Information not communicated understandably
When a standard element requires that information be shared with certain persons, the information is either not shared or not shared in a manner that allows for comprehension by the recipient.
Involvement by appropriate person(s) inadequate
When a standard element requires the involvement of certain persons, those persons are either not involved or not involved in a sufficient manner.
Non-compliance with law, regulation, or other rule
When a standard element requires compliance with a legal requirement or a process for achieving legal compliance, sufficient evidence of compliance or the compliance process is not demonstrated.
Policy/plan/procedure/practice not consistently implemented
When a standard element requires a policy/plan/procedure/practice, it exists but the actual performance does not occur with sufficient regularity to be deemed standard operating procedure.
Policy/plan/procedure/practice not developed
When a standard element requires a policy/plan/procedure/practice, it is not in existence.
Policy/plan/procedure/practice not implemented
When a standard element requires a policy/plan/procedure/practice, it exists but there is no actual performance.
Policy/plan/procedure/practice recently implemented
When a standard element requires a policy/plan/procedure/practice, it exists but the actual performance has not been in place for sufficient time to establish a track record.
Training inadequate When a standard element requires that certain training occur, it either does not occur or does not occur with sufficient regularity to be deemed standard operating procedure.
Evidence of conformance inadequate When the requirement of a standard element is not satisfied, or is inconsistently satisfied and no other reasons apply.
St. Joseph's Villa of Sudbury Accreditation Report 5
Standard Number Standard Text
Cre
de
ntia
ls in
ad
eq
ua
te
Da
ta o
r in
form
atio
n n
ece
ssa
ry to
ad
dre
ss c
on
form
an
ce n
ot
colle
cte
d a
nd
/or
eva
lua
ted
Do
cum
en
tatio
n in
ad
eq
ua
te
Effo
rt n
ot c
om
pre
he
nsi
ve
Fin
an
cia
l ra
tio c
alc
ula
tion
be
low
me
dia
n
Fre
qu
en
cy in
ad
eq
ua
te
Info
rma
tion
no
t co
mm
un
ica
ted
un
de
rsta
nd
ab
ly
Invo
lve
me
nt b
y a
pp
rop
ria
te p
ers
on
(s)
ina
de
qu
ate
No
n-c
om
plia
nce
with
law
, re
gu
latio
n, o
r o
the
r ru
le
Po
licy/
pla
n/p
roce
du
re/p
ract
ice
no
t co
nsi
ste
ntly
imp
lem
en
ted
Po
licy/
pla
n n
ot d
eve
lop
ed
Pro
ced
ure
/pra
ctic
e n
ot d
eve
lop
ed
Po
licy/
pla
n/p
roce
du
re/p
ract
ice
no
t im
ple
me
nte
d
Po
licy/
pla
n/p
roce
du
re/p
ract
ice
re
cen
tly im
ple
me
nte
d
Tra
inin
g in
ad
eq
ua
te
Evi
de
nce
of c
on
form
an
ce in
ad
eq
ua
te
1.H.5.c.(7) There are written emergency procedures: That address, as follows: Identification of essential services.
X X
1.H.5.c.(8) There are written emergency procedures: That address, as follows: Continuation of essential services.
X X
1.H.7.a.(1) Unannounced tests of all emergency procedures: Are conducted at least annually: On each shift.
X X
1.H.7.c.(1) Unannounced tests of all emergency procedures: Are analyzed for performance that addresses: Areas needing improvement.
X
1.H.7.c.(2) Unannounced tests of all emergency procedures: Are analyzed for performance that addresses: Actions to be taken.
X
1.H.7.c.(3) Unannounced tests of all emergency procedures: Are analyzed for performance that addresses: Results of performance improvement plans.
X
1.H.7.d. Unannounced tests of all emergency procedures: Are evidenced in writing, including the analysis.
X X
1.H.10.a. A written analysis of all critical incidents is provided to or conducted by the leadership: At least annually.
X X
2.A.1.c. Each program/service: Reviews the scope of services at least annually and updates it as necessary.
X
2.A.10.e.(7) Based on the scope of services, there is a written agreement: That contains information regarding: Refund policies.
X
2.A.32.b. Based on its scope of services, the program has a written philosophy of health and wellness for the persons served that: Addresses aging in place.
X
2.A.42.c. Leadership fosters a continuous learning environment for personnel that: Measures the effectiveness of the techniques used in the learning environment against a performance target.
X
Reasons for Partial or Non-conformance
6 St. Joseph's Villa of Sudbury Accreditation Report
Standard Number Standard Text
Cre
de
ntia
ls in
ad
eq
ua
te
Da
ta o
r in
form
atio
n n
ece
ssa
ry to
ad
dre
ss c
on
form
an
ce n
ot
colle
cte
d a
nd
/or
eva
lua
ted
Do
cum
en
tatio
n in
ad
eq
ua
te
Effo
rt n
ot c
om
pre
he
nsi
ve
Fin
an
cia
l ra
tio c
alc
ula
tion
be
low
me
dia
n
Fre
qu
en
cy in
ad
eq
ua
te
Info
rma
tion
no
t co
mm
un
ica
ted
un
de
rsta
nd
ab
ly
Invo
lve
me
nt b
y a
pp
rop
ria
te p
ers
on
(s)
ina
de
qu
ate
No
n-c
om
plia
nce
with
law
, re
gu
latio
n, o
r o
the
r ru
le
Po
licy/
pla
n/p
roce
du
re/p
ract
ice
no
t co
nsi
ste
ntly
imp
lem
en
ted
Po
licy/
pla
n n
ot d
eve
lop
ed
Pro
ced
ure
/pra
ctic
e n
ot d
eve
lop
ed
Po
licy/
pla
n/p
roce
du
re/p
ract
ice
no
t im
ple
me
nte
d
Po
licy/
pla
n/p
roce
du
re/p
ract
ice
re
cen
tly im
ple
me
nte
d
Tra
inin
g in
ad
eq
ua
te
Evi
de
nce
of c
on
form
an
ce in
ad
eq
ua
te
Reasons for Partial or Non-conformance
2.A.51.a.(1) The organization provides documented competency-based training for personnel, as appropriate to their roles: At: Orientation.
X
2.A.51.a.(2) The organization provides documented competency-based training for personnel, as appropriate to their roles: At: Regular intervals.
X X
2.A.51.b.(12)(a) The organization provides documented competency-based training for personnel, as appropriate to their roles: That includes: Gathering information about the person served in the following areas: History.
X X X
2.A.51.b.(12)(b) The organization provides documented competency-based training for personnel, as appropriate to their roles: That includes: Gathering information about the person served in the following areas: Current status.
X X X
2.A.51.b.(12)(c) The organization provides documented competency-based training for personnel, as appropriate to their roles: That includes: Gathering information about the person served in the following areas: Important memories.
X X X
2.A.51.b.(12)(d) The organization provides documented competency-based training for personnel, as appropriate to their roles: That includes: Gathering information about the person served in the following areas: Favorite stories.
X X X
2.A.51.b.(12)(e) The organization provides documented competency-based training for personnel, as appropriate to their roles: That includes: Gathering information about the person served in the following areas: Daily routines.
X X X
2.A.51.b.(12)(f) The organization provides documented competency-based training for personnel, as appropriate to their roles: That includes: Gathering information about the person served in the following areas: Comfort/reminiscence objects.
X X X
St. Joseph's Villa of Sudbury Accreditation Report 7
Standard Number Standard Text
Cre
de
ntia
ls in
ad
eq
ua
te
Da
ta o
r in
form
atio
n n
ece
ssa
ry to
ad
dre
ss c
on
form
an
ce n
ot
colle
cte
d a
nd
/or
eva
lua
ted
Do
cum
en
tatio
n in
ad
eq
ua
te
Effo
rt n
ot c
om
pre
he
nsi
ve
Fin
an
cia
l ra
tio c
alc
ula
tion
be
low
me
dia
n
Fre
qu
en
cy in
ad
eq
ua
te
Info
rma
tion
no
t co
mm
un
ica
ted
un
de
rsta
nd
ab
ly
Invo
lve
me
nt b
y a
pp
rop
ria
te p
ers
on
(s)
ina
de
qu
ate
No
n-c
om
plia
nce
with
law
, re
gu
latio
n, o
r o
the
r ru
le
Po
licy/
pla
n/p
roce
du
re/p
ract
ice
no
t co
nsi
ste
ntly
imp
lem
en
ted
Po
licy/
pla
n n
ot d
eve
lop
ed
Pro
ced
ure
/pra
ctic
e n
ot d
eve
lop
ed
Po
licy/
pla
n/p
roce
du
re/p
ract
ice
no
t im
ple
me
nte
d
Po
licy/
pla
n/p
roce
du
re/p
ract
ice
re
cen
tly im
ple
me
nte
d
Tra
inin
g in
ad
eq
ua
te
Evi
de
nce
of c
on
form
an
ce in
ad
eq
ua
te
Reasons for Partial or Non-conformance
2.A.51.b.(12)(g) The organization provides documented competency-based training for personnel, as appropriate to their roles: That includes: Gathering information about the person served in the following areas: People of importance.
X X X
2.B.10. Policies and written procedures allow the opportunity for the persons served to receive visitors 24 hours a day, if desired and the visit does not infringe upon the health, safety, or rights of any persons served.
X
8 St. Joseph's Villa of Sudbury Accreditation Report
Benchmarking This section of the Accreditation Report benchmarks your organization’s conformance to standards. By comparing strengths and areas for improvement with various comparator groups, benchmarking encourages your organization to improve effectiveness, efficiency, satisfaction, and access. This information should also stimulate discussions among stakeholders focused on better meeting the needs and preferences of the persons served. In addition, benchmarking:
Encourages a culture of continuous evaluation and improvement. Accelerates understanding of and agreement on areas for improvement. Helps prioritize improvement opportunities. Shifts internal thinking toward a focus on outcomes. Provides a reference to increase performance expectations. Motivates your team to work collaboratively to surpass benchmarks.
This report provides benchmarks (mean % of conformance) for each section of the ASPIRE to Excellence® quality framework.* When available, benchmark comparison groups include:
All surveyed organizations. All surveyed organizations in the same primary CARF customer service unit. Surveyed organizations with the same ownership type. Surveyed organizations in the same geographic region. Surveyed organizations with similar number of persons served annually. Surveyed organizations with similar staff size.
In addition, standards conformance for each organization undergoing resurvey is benchmarked against its previous survey in all standards areas.
Benchmark Comparison Groups
Primary area of accreditation: Aging Services (AS)
Ownership type: Private, Not for Profit
Geographic region: Canada–ON
Staff size (FTEs): 100–499
Persons served annually: 100–499
To receive the information contained in this section in an alternate format, please contact editing@carf.org.
* Excluding Governance.
St. Joseph's Villa of Sudbury Accreditation Report 9
All surveyed organizations
79.3%
88.7%
98.1%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
SJV
% of Conformance
Lead
ersh
ip
A: Assess the Environment
46.3%
81.7%
98.3%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
SJV
% of Conformance
Stra
tegi
c Pl
anni
ng
S: Set Strategy
10 St. Joseph's Villa of Sudbury Accreditation Report
All surveyed organizations — continued
60.0%
83.4%
99.8%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
SJV
% of Conformance
Inp
ut fr
om S
take
hold
ers
P: Persons Served and Other Stakeholders - Obtain Input
88.7%
94.7%
99.5%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
SJV
% of Conformance
Lega
l Req
uire
men
ts
I: Implement the Plan
St. Joseph's Villa of Sudbury Accreditation Report 11
All surveyed organizations — continued
69.2%
91.7%
99.2%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
SJV
% of ConformanceFina
ncia
l Pla
nnin
g an
d M
anag
emen
t
I: Implement the Plan
56.0%
79.7%
97.4%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
SJV
% of Conformance
Risk
Man
agem
ent
I: Implement the Plan
12 St. Joseph's Villa of Sudbury Accreditation Report
All surveyed organizations — continued
74.3%
84.0%
96.7%
95.6%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
SJV
% of Conformance
Hea
lth
and
Saf
ety
I: Implement the Plan
72.9%
87.5%
97.6%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
SJV
% of Conformance
Hum
an R
esou
rces
I: Implement the Plan
St. Joseph's Villa of Sudbury Accreditation Report 13
All surveyed organizations — continued
63.8%
85.2%
99.0%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
SJV
% of Conformance
Tech
nolo
gy
I: Implement the Plan
86.5%
93.4%
98.6%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
SJV
% of Conformance
Righ
ts o
f Per
sons
Ser
ved
I: Implement the Plan
14 St. Joseph's Villa of Sudbury Accreditation Report
All surveyed organizations — continued
50.5%
74.7%
96.3%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
SJV
% of Conformance
Acc
essi
bili
ty
I: Implement the Plan
41.9%
70.0%
97.3%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
SJV
% of Conformance
Perf
orm
ance
Mea
sure
men
t an
d
Man
agem
ent
R: Review Results
St. Joseph's Villa of Sudbury Accreditation Report 15
All surveyed organizations — continued
22.0%
41.7%
92.9%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
SJV
% of Conformance
Perf
orm
ance
Im
pro
vem
ent
E: Effect Change
16 St. Joseph's Villa of Sudbury Accreditation Report
Other benchmarks
97.2%
97.8%
95.7%
96.8%
95.7%
100.0%
0% 20% 40% 60% 80% 100%
100 to 499 Persons Served
100 to 499 FTEs
Ontario
Private, Not for Profit
Aging Services
SJV
% of Conformance
Lead
ersh
ipA: Assess the Environment
97.8%
99.1%
98.1%
98.1%
96.9%
100.0%
0% 20% 40% 60% 80% 100%
100 to 499 Persons Served
100 to 499 FTEs
Ontario
Private, Not for Profit
Aging Services
SJV
% of Conformance
Stra
tegi
c Pl
anni
ng
S: Set Strategy
St. Joseph's Villa of Sudbury Accreditation Report 17
Other benchmarks — continued
99.6%
99.9%
99.8%
99.7%
99.7%
100.0%
0% 20% 40% 60% 80% 100%
100 to 499 Persons Served
100 to 499 FTEs
Ontario
Private, Not for Profit
Aging Services
SJV
% of Conformance
Inp
ut fr
om S
take
hold
ers
P: Persons Served and Other Stakeholders -Obtain Input
99.5%
99.7%
99.6%
99.3%
99.5%
100.0%
0% 20% 40% 60% 80% 100%
100 to 499 Persons Served
100 to 499 FTEs
Ontario
Private, Not for Profit
Aging Services
SJV
% of Conformance
Lega
l Req
uire
men
ts
I: Implement the Plan
18 St. Joseph's Villa of Sudbury Accreditation Report
Other benchmarks — continued
99.1%
99.4%
99.1%
99.3%
99.1%
100.0%
0% 20% 40% 60% 80% 100%
100 to 499 Persons Served
100 to 499 FTEs
Ontario
Private, Not for Profit
Aging Services
SJV
% of Conformance
Fina
ncia
l Pla
nnin
g an
d M
anag
emen
tI: Implement the Plan
97.3%
98.2%
97.9%
96.7%
97.4%
100.0%
0% 20% 40% 60% 80% 100%
100 to 499 Persons Served
100 to 499 FTEs
Ontario
Private, Not for Profit
Aging Services
SJV
% of Conformance
Risk
Man
agem
ent
I: Implement the Plan
St. Joseph's Villa of Sudbury Accreditation Report 19
Other benchmarks — continued
96.3%
96.8%
95.9%
95.8%
96.0%
95.6%
0% 20% 40% 60% 80% 100%
100 to 499 Persons Served
100 to 499 FTEs
Ontario
Private, Not for Profit
Aging Services
SJV
% of Conformance
Hea
lth
& S
afet
yI: Implement the Plan
97.1%
98.1%
97.0%
97.2%
97.3%
100.0%
0% 20% 40% 60% 80% 100%
100 to 499 Persons Served
100 to 499 FTEs
Ontario
Private, Not for Profit
Aging Services
SJV
% of Conformance
Hum
an R
esou
rces
I: Implement the Plan
20 St. Joseph's Villa of Sudbury Accreditation Report
Other benchmarks — continued
98.8%
99.5%
98.7%
98.7%
98.6%
100.0%
0% 20% 40% 60% 80% 100%
100 to 499 Persons Served
100 to 499 FTEs
Ontario
Private, Not for Profit
Aging Services
SJV
% of Conformance
Tech
nolo
gyI: Implement the Plan
98.5%
98.6%
98.4%
98.3%
98.3%
100.0%
0% 20% 40% 60% 80% 100%
100 to 499 Persons Served
100 to 499 FTEs
Ontario
Private, Not for Profit
Aging Services
SJV
% of Conformance
Righ
ts o
f Per
sons
Ser
ved
I: Implement the Plan
St. Joseph's Villa of Sudbury Accreditation Report 21
Other benchmarks — continued
96.4%
97.6%
95.5%
95.6%
94.0%
100.0%
0% 20% 40% 60% 80% 100%
100 to 499 Persons Served
100 to 499 FTEs
Ontario
Private, Not for Profit
Aging Services
SJV
% of Conformance
Acc
essi
bili
tyI: Implement the Plan
97.3%
98.2%
98.3%
96.8%
99.2%
100.0%
0% 20% 40% 60% 80% 100%
100 to 499 Persons Served
100 to 499 FTEs
Ontario
Private, Not for Profit
Aging Services
SJV
% of Conformance
Perf
orm
ance
Mea
sure
men
t an
d
Man
agem
ent
R: Review Results
22 St. Joseph's Villa of Sudbury Accreditation Report
Other benchmarks — continued
92.5%
95.4%
94.0%
91.1%
96.8%
100.0%
0% 20% 40% 60% 80% 100%
100 to 499 Persons Served
100 to 499 FTEs
Ontario
Private, Not for Profit
Aging Services
SJV
% of Conformance
Perf
orm
ance
Im
pro
vem
ent
E: Effect Change
St. Joseph's Villa of Sudbury Accreditation Report 23
Previous survey
100.0%
100.0%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
Lead
ersh
ip
A: Assess the Environment
100.0%
100.0%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
Stra
tegi
c Pl
anni
ng
S: Set Strategy
24 St. Joseph's Villa of Sudbury Accreditation Report
Previous survey — continued
100.0%
100.0%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
Inp
ut fr
om S
take
hold
ers
P: Persons Served and Other Stakeholders - Obtain Input
100.0%
100.0%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
Lega
l Req
uire
men
ts
I: Implement the Plan
St. Joseph's Villa of Sudbury Accreditation Report 25
Previous survey — continued
91.8%
100.0%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
Fina
ncia
l Pla
nnin
g an
d M
anag
emen
t
I: Implement the Plan
65.6%
100.0%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
Risk
Man
agem
ent
I: Implement the Plan
26 St. Joseph's Villa of Sudbury Accreditation Report
Previous survey — continued
91.9%
95.6%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
Hea
lth
and
Saf
ety
I: Implement the Plan
96.2%
100.0%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
Hum
an R
esou
rces
I: Implement the Plan
St. Joseph's Villa of Sudbury Accreditation Report 27
Previous survey — continued
100.0%
100.0%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
Tech
nolo
gy
I: Implement the Plan
100.0%
100.0%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
Righ
ts o
f Per
sons
Ser
ved
I: Implement the Plan
28 St. Joseph's Villa of Sudbury Accreditation Report
Previous survey — continued
100.0%
100.0%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
Acc
essi
bili
ty
I: Implement the Plan
100.0%
100.0%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
Perf
orm
ance
Mea
sure
men
t an
d M
anag
emen
t
R: Review Results
St. Joseph's Villa of Sudbury Accreditation Report 29
Previous survey — continued
100.0%
100.0%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
Perf
orm
ance
Im
pro
vem
ent
E: Effect Change
98.3%
98.2%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
A. P
rogr
am/S
ervi
ce S
truc
ture
Section 2. Care Process for the Persons Served
30 St. Joseph's Villa of Sudbury Accreditation Report
Previous survey — continued
100.0%
99.0%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
B. C
ongr
egat
e Re
sid
enti
al P
rogr
ams
Section 2. Care Process for the Persons Served
100.0%
100.0%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
D. P
erso
n-C
entr
ed L
ong-
Term
Car
e C
omm
unit
y
Section 3. Program Specific Standards
St. Joseph's Villa of Sudbury Accreditation Report 31