Guide for Developing Qmentum Plans and Frameworks...Guide for Developing. Qmentum Plans and...

Guide for Developing Qmentum Plans and Frameworks

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Guide for DevelopingQmentum Plans and Frameworks

Contents

Community Needs Assessment .....................................................................................................3

Strategic Plan ........................................................................................................................................7

Operational Plan ............................................................................................................................... 11

Integrated Quality Management Framework ........................................................................ 13

Ethics Framework ............................................................................................................................. 15

Communication Plan ...................................................................................................................... 17

Client Safety Plan ............................................................................................................................. 21

Disaster and Emergency Plan ...................................................................................................... 25

1Accreditation

Canada

Guide for DevelopingQmentum Plans and Frameworks

This Qmentum Plans and Frameworks Guide is provided for organizations that are developing the plans and frameworks required by Accreditation Canada’s Qmentum accreditation program. It describes some of the key elements of these plans, answers frequently asked questions, and provides sample templates or examples for:

Community needs assessments �Strategic plans �Operational plans �Integrated quality management frameworks, including risk management �Ethics frameworks �Communication plans �Client safety plans �Disaster and emergency plans �

The information in this Guide will be particularly helpful for organizations with limited experience in developing and using these types of plans, as well as for those wishing to enhance their current plans.

Using the information and the templates in this Guide is optional. It offers one approach that may be helpful, but organizations that already have plans and frameworks that meet their needs and that also address the requirements of the standards may choose to continue to use them.

Accreditation Canada recognizes that all of these plans and frameworks cannot be developed simultaneously. Organizations should consider their already established goals and objectives, as well as input from their Accreditation Specialist, to determine which plans are most important for their current needs. Plans do not need to be developed in the order they are presented here.

This Guide is written specifically for Accreditation Canada client organizations, but it is also used by surveyors and Accreditation Specialists. This helps ensure that everyone who is part of the process has the same information throughout the ongoing cycle of learning and improvement.

Share and share alike… If your organization has developed successful plans or templates, consider sharing them with other Accreditation Canada organizations. Call your Accreditation Specialist to help develop this exciting opportunity for knowledge transfer!

For more information, contact your Accreditation Specialist, or call 613-738-3800, or 1-800-814-7769.

3Accreditation

Canada

Community Needs Assessment

This section of the Guide is for organizations that may want assistance creating a community needs assessment. It will be particularly helpful for organizations with limited experience in developing and using community needs assessments, as well as for those wishing to enhance their current assessment process.

Organizations that already have a community needs assessment process that works well and that addresses the requirements of the standards should continue to use it.

Summary of key standards requirementsQmentum standards require that an organization’s board and leadership collect or have access to a community needs assessment, and use it to inform strategic, operational, and service planning.

The community needs assessment should be developed in collaboration with partners and stakeholders, and be up-to-date, easy to understand, and shared with staff, partners and others who may find it useful.

Refer to Qmentum standards, criteria, and guidelines for detailed requirements.

Elements of a community needs assessmentThe community needs assessment is a study that provides a comprehensive and unbiased overview of the needs of the community. It includes trends and changes in the environment, including demographic information such as age, cultural diversity, literacy, and language; the impact of the determinants of health such as housing conditions and socioeconomic status; the rates of risk factors such as smoking or overweight/obesity; and feedback from clients and the community about their health needs.

Questions and Answers1. Where can we find information on the health status of the populations we serve?

Information is usually available through internal health or service records, client files, and your annual report. These documents can provide information on the number of clients, ages, genders, diagnoses, sources of admission, and reasons for the service provided.

External sources of health status information include the Canadian Institute for Health Information, the Public Health Agency of Canada, district health councils, regional health boards or authorities, and census data.

Guide for Developing Qmentum Plans and Frameworks4

2. How often should we carry out a community needs assessment?

There is no set guideline as to how often your organization should complete an assessment. As you are aware, change is inevitable – organizations merge, health regions re-structure, health status and community demographics change, new health care knowledge emerges, service providers move away, and new community partnerships develop – and any of these can trigger the need for a new assessment. Many organizations tie their community needs assessment process to their strategic planning process.

To deliver the right services to your community, you need to continuously plan, evaluate, and modify your services. If you are regularly reviewing trends, collecting information, and have mechanisms in place to hear from your clients and community, you will stay aware of health status and health needs. And remember you don’t have to do this alone – work with your community and your partners.

3. The standards refer to sharing information from the community needs assessment. Do we need to follow a particular procedure or format to do so?

No. You have the flexibility to identify how information from the community needs assessment is disseminated, in what format, the degree of detail, and any restrictions, e.g. privacy legislation.

5Accreditation

Canada

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7Accreditation

Canada

Strategic Plan

This section of the Guide is for organizations that may want assistance creating a strategic plan. It will be particularly helpful for organizations with limited experience in developing and using strategic plans, as well as for those wishing to enhance their current strategic planning process.

Organizations that already have a strategic planning process that works well and that addresses the requirements of the standards should continue to use it.

Summary of key standards requirementsQmentum standards required that governing bodies lead a strategic planning process, have a defined process for developing and updating the organization’s vision and strategic plan, and that the plan include measureable goals and objectives.


Elements of a strategic planA strategic plan is a formal, written document that defines the long-term direction of an organization as a whole. It sets broad strategic goals and contributes to effective decision-making with regard to resource allocation or difficult operational choices. It addresses broad questions such as: Who are we? Where are we now? What is the environment (physical, cultural, political) in which we operate? Where do we want to go, and how should we get there?

Often the most important aspect of the strategic plan is not the document itself, but the process used to develop it. An effective strategic planning process, with broad stakeholder involvement, helps ensure that the plan is understood and supported by everyone in the organization, and ultimately increases the likelihood of achieving the strategic goals.

A strategic plan should identify strategic themes and overarching focus areas, strategic initiatives, goals and objectives with timeframe(s), and specific outcomes and measurements. Here are some common strategic planning steps, adapted from Baker et. al.1:

1. Gather the right people, including internal and external stakeholders. 2. Conduct an internal and external environmental scan.

1 Baker et al: Building a vision for the future: Strategic planning in a shared governance nursing organization. Semi-nars for Nurse Managers 2000;8(20):98-106.


3. Identify strengths, weaknesses, opportunities and threats. This is commonly called a SWOT analysis.

4. Identify broad strategic themes or overarching areas – these could be client service or best practices.

5. Break the themes into strategic initiatives, such as family-centred care, patient safety, or strengthening health systems and community capacity.

6. Identify goals and timelines for each strategic initiative. This becomes the implementation plan, e.g. identify, implement, and promote an optimal model of family-centred care.

7. Identify outcomes and measurements for each goal, e.g. 80% of clients and 80% of service providers are highly satisfied with family-centred care model.

8. Determine how the outcomes will be measured (e.g. satisfaction surveys) and identify appropriate measures.

9. Develop action plans to identify activities required to meet the goals.10. Once the strategic plan is drafted, ask staff and other stakeholders who were not directly

involved to provide input.11. Communicate the strategic plan inside and outside the organization.12. Review the strategic plan regularly, to chart progress and to bring new critical thinking to

the plan.

In summary, while the terminology each organization uses may differ, strategic plans usually contain:

Strategic themes/overarching focus areas �Strategic initiatives �Goals, action plans, and timelines �Outcomes and measurements �

Questions and Answers

1. How do we assess the risks and opportunities when developing our strategic plan?

It’s important that your governing body be familiar with the environment – it can be a valuable resource in anticipating changes that may become risks or opportunities for the organization, assessing these risks and opportunities, and incorporating strategies to address them into the strategic plan.

For example, one of your strategic priorities may be to expand the physical space to provide better patient care. There may be risks associated with delays in obtaining ministry of health approval or in achieving fundraising targets. Identifying potential risks up front and developing contingency plans to address them can help ensure that your priority is sound, and achievable.

9Accreditation

Canada

2. How do we define measurable goals and objectives for the strategic plan?

The strategic plan needs to identify the specific goals and objectives needed to achieve the plan, as well the methods by which the goals and objectives will be achieved. Following from the example above where the goal is to expand the physical space, a measureable goal would be to obtain ministry of health (or whatever legislative body is involved) approval for the expansion by a certain date. Responsibility for achieving this goal would then be assigned to a specific individual who would liaise with the ministry – most likely the CEO.

3. Once our strategic plan is complete, who needs to know about it?

Your strategic plan should be communicated to all your stakeholders, internal and external. You have probably been communicating with them throughout the development process, but you should ensure they are fully aware of the final decisions on key strategic initiatives and goals, how these were developed, and how they will guide future activities.

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11Accreditation

Canada

Operational Plan

This section of the Guide is for organizations that may want assistance creating operational plans. It will be particularly helpful for organizations with limited experience in developing and using operational plans, as well as for those wishing to enhance their current operational planning process.

Organizations that already have an operational planning process that works well and that addresses the requirements of the standards should continue to use it.

Summary of key standards requirementsQmentum standards require organizations to develop annual operational plans that identify the resources, systems, and infrastructure needed to deliver services. The operational plans guide day-to-day operations and should be linked to the strategic plan and strategic goals.


Elements of an operational planAn operational plan summarizes the activities to be undertaken in the coming year toward meeting the strategic goals, and identifies the necessary processes, actions, and resources.

The operational plan breaks the broad strategic goals into smaller, more manageable pieces, each with their own operational objectives.


1. What is the link between a strategic plan and an operational plan, and, since we are a small organization, can we combine them into one?

The operational plan stems from the strategic plan. The operational plan is a detailed action plan to help your organization move toward achieving its strategic goals. The strategic plan identifies broad strategic directions and goals, while the operational plan outlines how these will be achieved (activities, resources, responsibilities, and time frames).

And no, these two plans cannot be combined – since they have different purposes, they need to be two separate (but linked) documents. Your strategic plan provides direction and goals for a longer period of time than your operational plan, and it builds a longer-term, broader vision for the future. Your operational plan outlines what you plan to do in the next year or so to help achieve the strategic goals.


2. How do we know if our operational plan is a success?

One way of knowing your operational plan is a success is if, in the long term, you achieve your strategic goals! Your leadership team may want to select particular methods to monitor the implementation of the operational plan, such as report cards (e.g. balanced scorecards), financial reporting tools (e.g. forecast and actual budgets), and project management tools.

Sample template for an operational plan to address the strategic goal of adopting patient safety as a written, strategic goal

Operational objective

Actions Resources Deliverable Measure of success

Timeline

To strengthen our patient safety culture and enhance our patient safety capacity as an organization

Include a new, written, patient safety strategic goal as part of the strategic plan and the annual report

Short-term, ad hoc committee comprised of 2 board members, CEO, and Communi-cations Specialist

Newly written strategic goal: The organization recognizes patient safety as a fundamental element in everything we do and for everyone we serve

Written goal included in both the strategic plan and the annual report

By fiscal year end

OR

As part of the next revision to the strategic plan, or as part of the next annual report

13Accreditation

Canada

Integrated Quality Management Framework

This section of the Guide is for organizations that may want assistance creating an integrated quality management framework. It will be particularly helpful for organizations with limited experience in developing and using quality management frameworks, as well as for those wishing to enhance their current framework.

Organizations that already have an integrated quality management framework that works well and that addresses the requirements of the standards should continue to use it.

Summary of key standards requirementsQmentum requires organizations to have a formal, integrated, quality management framework that includes a risk management plan to identify, report, assess, and manage risk. As part of this process, the organization’s leaders are expected to manage contracted services safely; review the frequency and severity of sentinel events, adverse events, and near misses; and select and monitor process and outcome measures to evaluate the organization’s performance.


Elements of an integrated quality management frameworkAn integrated quality management framework helps the organization develop and demonstrate a commitment to quality and safety at all levels. Developing and implementing the framework is one way for the organization to monitor and improves its quality of care and service over a particular period of time.

The framework should incorporate risk and utilization management; performance measurement, including monitoring of strategic goals; client safety; and quality improvement. These activities are interrelated and must be coordinated.

Through its integrated quality management activities, an organization can demonstrate its recognition that systemic change requires a commitment to safety and quality at all levels of the organization.


1. Our organization provides service to separate sites and programs. Can we develop just one integrated quality management plan?

Yes. In fact, one plan is often the most efficient way to ensure your quality management plan is integrated across the whole organization.


2. What does it mean to integrate a risk management approach into our quality framework?

You need to assess your organization’s actual and potential risks, and then incorporate strategies to manage these risks into the quality management framework. Rather than being separate from quality improvement, risk management should be an integral part of the quality improvement process. For example, if you identify contract management as a risk area, this becomes part of your quality improvement agenda and you would develop competency and quality indicators for specific contracted services.

3. Who is responsible for the integrated quality management framework?

It depends on the size and scope of the organization. In a very small organization that does not have a Board of Directors, the CEO may be responsible. In a larger organization, there may be a quality council or another group that manages quality improvement activities. Most important, for quality improvement to be successful all employees must understand that each person holds some responsibility for the quality of care and service in the organization as a whole.

Example: Using an integrated quality management framework

An adverse event has been reported by Team X. In keeping with its integrated quality management approach, the organization assigned an interdisciplinary team to conduct a root cause analysis. The analysis revealed poor communication within the team as the root cause of the adverse event. Subsequently:

The team studied and discussed ways to address its communication issues, and �decided to implement the SBAR technique (Situation / Background / Assessment / Recommendation) to structure communication about a patient’s condition among its members. The organization did not assume that Team X is the only team with communication �issues. It asked questions such as, Does the poor communication on this team tell us anything about communication within other teams or our organization as a whole? How can communication among service providers be strengthened throughout our organization? and What improvement opportunities can we identify from this event that could be implemented throughout the organization? Answering these questions led to a number of organization-wide quality improvement initiatives related to communication.

In this example, the organization’s integrated quality management approach linked the risk management activities associated with an adverse event to its quality improvement process, addressing safety and quality improvement at clinical, interpersonal, and organizational levels.

15Accreditation

Canada

Ethics framework

This section of the Guide is for organizations that may want assistance creating an ethics framework. It will be particularly helpful for organizations with limited experience in developing and using ethics frameworks, as well as for those wishing to enhance their current framework.

Organizations that already have an ethics framework that works well and that addresses the requirements of the standards should continue to use it.

Summary of key standards requirementsQmentum standards require organizations to develop and implement a written ethics framework that is adopted by the governing body and that defines formal processes for managing ethics-related issues and concerns. The organization must also ensure that staff and service providers know about the ethics framework and how to implement it.


Elements of an ethics frameworkHealth care providers and administrators face many ethical and moral dilemmas in the course of their work (e.g., care decisions, informed consent, research projects, resource allocation challenges, disclosure of risk). An ethics framework is an analytical tool to help guide ethical decision-making.


1. Our organization has a code of ethics for all staff. Does this meet the requirement for an ethics framework?

No. An ethics framework is not a code of ethics. A code of ethics addresses the general norms and expectations of professional behaviour, while an ethics framework is a tool to help guide decisions that have ethical implications. An ethics framework helps staff identify and respond appropriately to ethical issues or problems.


2. Accreditation Canada standards refer to an organization’s values. What is the link between values and the ethics framework?

Accreditation Canada defines values as moral principles and beliefs that guide behaviour. Defining your organizational values helps to establish parameters for expected staff behaviour and acceptable relationships with other organizations. Your organization’s core values will drive its decisions and actions, and these need to be linked to the ethics framework.

3. We are required to develop our capacity to apply the ethics framework. What does this mean?

It is important that you help your staff, leaders, service providers, and board members develop and enhance their ethics-related knowledge. The more information they have about ethics, ethics-related skills, and best practices in ethics, the more they are able to work with an ethics framework and successfully manage ethical issues within the organization.

Developing and enhancing ethics capacity can be achieved by providing access to formal ethics education and training, ensuring ethics frameworks and tools are available, providing forums for case reviews, disseminating best practices in ethics, and working with ethics consultants. You can also build ethics-related capacity by involving staff, service providers, community representatives, and clients in ethics-related discussions and decision-making.

Example: Using an ethics Framework

1. Identify the ethical issue, being very clear about the ethical question(s) involved, e.g. access to prophylaxis during a pandemic, obtaining informed consent, or a resource allocation decision.

2. Gather as much information as you can about the issue. 3. Evaluate alternative actions from various ethical perspectives. For example, in the case

of resource allocation, an organization may consider the necessity of reductions in patient services (supply and demand), procedural justice (decision makers, consultation, transparency), and distributive justice (equity, importance/efficacy, balance, evidence, loyalty).2

4. If feasible, make a decision and test it to evaluate the results.5. Reflect on the result. If necessary, consider what could have been done differently.

2 Vancouver Coastal Health Ethics Committee. How to Make Allocation Decisions: A theory and test questions. Healthcare Management Forum 2005;18(1):32-33.

17Accreditation

Canada

Communication Plan

This section of the Guide is for organizations that may want assistance creating a communications plan. It will be particularly helpful for organizations with limited experience in developing and using communications plans, as well as for those wishing to enhance their current communications planning process.

Organizations that already have a communications planning process that works well and that addresses the requirements of the standards should continue to use it.

Summary of key standards requirementsQmentum requires that the governing body work with the CEO to establish a communication plan to disseminate information to, and receive information from, stakeholders.


Elements of a communications planA communications plan is a written document that helps clarify who you want to reach with a particular message, what the message is, and how you are going to reach them. It identifies:

Objectives What do you want to accomplish? (Do you want people to take a specific action? Just be aware and informed?)

Target audiences Who do you want to tell? Who can help you tell them? Key messages What do you want to tell them?Strategies and timelines

How will you tell them, and when? (Options include Intranet, staff meetings, newsletters, website, annual report, newspapers or other media, community meetings)

Outcomes How will you know your communication objective has been achieved?

Including an outcomes evaluation component as part of the communications plan is a valuable way to assess whether the objectives have been achieved.


1. Should our communication plan enable two-way communication?

Yes. The communication plan should enable open, two-way communication with your internal and external stakeholders, and identify the various ways you will respond to them.


2. What are “target audiences”?

Target audiences are the people you want to reach with your message. This may include any or all of staff, volunteers, other service providers, patients/clients, Board of Directors, suppliers, community groups, other stakeholders, or the general public. Target audiences differ according to the messages being disseminated; not all audiences need the same amount or type of information. As a rule, you will usually find that you automatically tailor the information according to who will be receiving it.

For instance, if you are working on improving hand hygiene, your target audiences for communicating a new policy or procedure will likely be staff, service providers, volunteers, and patients or clients.

3. What role does our Board of Directors play in developing the communication plan?

Your Board of Directors does not develop the communication plan. The Board’s role is to oversee the implementation of the plan, ensuring, through your leadership team, that the plan is in effect and effective.

19Accreditation

Canada

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21Accreditation

Canada

Client Safety Plan

This section of the Guide is for organizations that may want assistance creating a client safety plan. It will be particularly helpful for organizations with limited experience in developing and using client safety plans, as well as for those wishing to enhance their current client safety planning process.

Organizations that already have a client safety planning process that works well and that addresses the requirements of the standards should continue to use it.

Summary of key StandardS requirementS

Qmentum requires that organizations develop and implement a client safety plan and client safety improvements. The organization’s leaders are expected to assign responsibility for implementing and monitoring the client safety plan, and for leading client safety improvement activities.


Elements of a client safety planA client safety assessment is a way to identify client safety issues within the organization. Using this information to develop a client safety plan can identify steps that have been taken and that will be taken to address client safety issues.

Client safety may be improved by coaching and mentoring staff and service providers, leading client safety leadership walkabouts, implementing organization-wide client safety initiatives to promote widespread learning, accessing evidence and best practice, encouraging staff and service provider innovation, providing feedback to staff and service providers on client safety issues and safety improvement suggestions, recognizing staff and service providers for their suggestions to improve client safety, and acting on staff and service provider recommendations.


1. We are just starting to talk about client safety and to conduct a client safety assessment. Is it too soon to develop and implement a client safety plan?

Through your client safety assessment, you have taken an important first step in developing an organizational culture based on sound and clearly articulated principles of client safety and quality improvement. To build awareness and understanding of the importance of client safety within your organization, you need to educate and inform your staff. A widely


disseminated client safety plan, with specific goals based on your safety assessment, is one way to help staff learn about client safety and make it an integral part of their day-to-day work.

2. What timeframe should our client safety plan cover?

Remember that the intent of the plan is to address the client safety issues and concerns you find during your client safety assessment. Therefore, depending on the extent of the issues, your plan may span a year or longer, and may need to include a global client safety strategy. Regardless of the timeframe, your client safety plan should identify specific steps and improvement initiatives, and timelines for each. It is important to regularly monitor and update the client safety plan to take into account new information, internal or external constraints, and changes in organizational capacity and resources.

3. Who is responsible for implementing and monitoring our client safety plan?

Your leadership team should identify who is responsible for implementing and monitoring the client safety plan and leading client safety improvement activities. This responsibility may be assigned to a council, a committee, a team, staff members, or other client safety champions. However it is structured, everyone should know who is responsible for organization-wide client safety as well for safety within specific work areas when these responsibilities are assigned to different people or groups.

Sample template for a client safety plan addressing the goal of decreasing client falls

Steps Responsibility Action and Timelines OutcomesEstablish interdisciplinary Falls Prevention Team

Director of Nursing

Identify members and conduct first meeting (October)

All areas and disciplines represented

Team develops and approves terms of reference

Falls Prevention Team identifies populations at risk for falls

Falls Prevention Team

Each team member consults with their service areas to identify populations at risk

Team receives information and prioritizes if necessary(November)

At-risk populations identified

Information is communicated throughout the organization, including with clients/patients and families

Falls Prevention Team identifies the specific needs for populations at risk for falls

Falls Prevention Team

Brainstorm and discuss specific needs

Consult literature

Consult partner organizations(December)

Specific needs and requirements identified, e.g. hip protectors for elderly population; handrails and other supports during transfers to/from bathroom; medication reviews for clients taking multiple medications

23Accreditation

Canada

Sample template for a client safety plan addressing the goal of decreasing client falls (cont’d)

Steps Responsibility Action and Timelines Outcomes

Implement falls prevention strategy

Led by Falls Prevention Team with involvement of all care providers

Implement new policies or procedures as requires

Obtain or install necessary equipment or devices

Educate staff, service providers, and clients/patients

Launch organizational communication plan to support falls prevention strategy(January)

Staff understanding of new policies and procedures, and use of new equipment and devices

Falls decreased on all units (monthly monitoring)

Evaluate to improve falls prevention strategy

Led by Falls Prevention Team with involvement of all care providers

Review falls data, trends, degree of injury

Work with care and service providers to identify other ways to decrease falls for specific populations(January to June)

Improve falls prevention strategy as required

25Accreditation

Canada

Disaster and Emergency Plan

This section of the Guide is for organizations that may want assistance creating a disaster and emergency plans. It will be particularly helpful for organizations with limited experience in developing and using disaster and emergency plans, as well as for those wishing to enhance their current disaster and emergency planning process.

Organizations that already have a disaster and emergency planning process that works well and that addresses the requirements of the standards should continue to use it.

Summary of key standards requirementsQmentum requires that an organization’s leaders prepare a plan to address the risk of disasters and emergencies, and that the plan be aligned with those of partner organizations and local, regional and provincial governments. The plan needs to be integrated with other partners and governments to facilitate large-scale responses.

The disaster and emergency plan should identify clear lines of responsibility, communication systems, emergency response systems, and methods to regularly test and update the plans.

Also, when disasters or emergencies occur, those involved should be provided with support and debriefing opportunities.


Elements of a disaster and emergency planA disaster and emergency plan outlines the steps and activities to be taken during a disaster or emergency. To name just a few, a disaster or emergency includes events such as a client requiring resuscitation; a fire, bomb threat, or abducted child; a natural or man-made disaster in the community; or an outbreak or pandemic.

Depending on the nature of the organization, the plan should address topics such as: notifying the police or other emergency services; isolating, evacuating, and relocating clients; deciding what services the organization can continue to deliver; and taking in mass casualties.


1. Our organization provides service to separate sites and public health programs. Can we develop just one disaster and emergency plan?

Yes. You will need to include actions that may be specific to each site or program, but the coordination and maintenance of the plan can be done centrally.


2. Other than ensuring they are fully aware of the disaster and emergency plan, what else can we do to help our staff be prepared for a disaster or emergency?

Testing the plan regularly, through drills or other exercises, is the most effective way to ensure staff readiness. If you have developed organizational, department, team, or unit call-back or phone fan-out systems, remember to keep the phone numbers up to date – and test those systems to ensure that the phone numbers are current and that staff know what to do.

Developing a checklist of key actions to be taken during a disaster or emergency will assist those who are in charge of disaster planning, making it easier to put the plan into effect and ensure nothing is forgotten. Keep the checklist in a central location, print it on brightly coloured paper so it is easy to find, and enclose it in a plastic cover or folder for added protection.

You may also wish to use your staff bulletin board, newsletter, or Intranet to provide ongoing information and reminders about staff responsibilities during a disaster or emergency.

Sample template for emergency plan to address the threat of violence to staff member

Steps Responsibility Action and Timelines OutcomesEstablish interdisciplinary planning committee for threat of personal violence

Senior Admin responsible for environment services

1) Assemble members from different parts of the organization who deal directly with the public (June)

2) Designate a steering committee (June)

3) Designate an education sub-committee (July)

1) All areas and disciplines are represented

2) The steering committee is responsible to ensure the plan is developed

3) The education sub-committee ensures that education plans are made as the plan unfolds, rather than as an add-on at the end of the plan

Determine disaster response capability and compare to the potential types of threats of personal violence with which the organization may be faced

Sub-committee 1) Thorough review of current plan (July)

2) Brainstorm – then verify – threats of potential violence for which the organization needs to be prepared (July)

The whole committee is aware of the current situation and will set priorities for development

27Accreditation

Canada

Sample template for emergency plan to address the threat of violence to staff member (cont’d)

Steps Responsibility Action and Timelines Outcomes

Link with police and other organizations that could respond in an emergency

Steering Committee

1) Determine who in the community would respond to the organization in this situation (July)

2) Designate committee member(s) to liaise with the community partners (August)

3) Invite external stakeholders to contribute to the development of the response plan for this scenario (August)

1) All committee members are aware of external resources

2) These members bring back information to the committee to incorporate into the response plan

3) Committee members are aware of roles and responsibilities for such a threat

Define lines of authority, personnel roles and communication flow

Sub-committees Develop details of the plan as to who would be in charge. For example, supervisor in the area affected to notify senior administration to put plan into action; designated person to reassure other staff and patients, visitors, volunteers; designated person to deal with media (September)

Clearly defined roles for each aspect of the plan – if the plan is put into action, everyone ful-fills his/her role appro pria tely and the situation is diffused or controlled appropriately

Link with police and other organizations that could respond in an emergency

Steering Committee

1) Determine who in the community would respond to the organization in this situation (July)

2) Designate committee member(s) to liaise with the community partners (August)

3) Invite external stake-holders to contribute to the development of the response plan for this scenario (August)

1) All committee members are aware of external resources

2) These members bring back information to the committee to incorporate into the response plan

3) Committee members are aware of roles and responsibilities for such a threat

Define lines of authority, personnel roles and communication flow

Sub-committees Develop details of the plan as to who would be in charge. For example, supervisor in the area affected to notify senior administration to put plan into action; designated person to reassure other staff and patients, visitors, volunteers; designated person to deal with media (September)

Clearly defined roles for each aspect of the plan – if the plan is put into action, everyone ful-fills his/her role appro pria tely and the situation is diffused or controlled appropriately

accreditation-canada.ca

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January 19, 2009

Guide for Developing Qmentum Plans and Frameworks...Guide for Developing. Qmentum Plans and...

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