Updates from the Non-Hospital Medical and Surgical Facilities Program

All medical staff—including surgical assists—must be authorized by the NHMSFP Committee

Medical directors are reminded that, in accordance with section 5-5 of the Bylaws made under the Health Professions Act, an initial application for appointment of all medical staff to the facility must be submitted to the Non-Hospital Medical and Surgical Facilities Program Committee for approval, including surgical assists. In addition, medical directors are responsible for ensuring that members of their medical staff perform only those procedures which they are individually authorized by the committee to perform.

Continuous quality improvement

Non-Hospital Medical and Surgical Facility Program accreditation involves preparing for an accreditation visit; and, even more importantly, it requires facility commitment to continuous self-assessment and evaluation of the quality and safety of patient care delivery. Between accreditation visits, non-hospital facilities, through their own quality improvement (QI) programs, are expected to continually evaluate their performance to identify their strengths, risks and opportunities for improvement—and to take action to correct deficiencies.

During the 2014-15 accreditation cycle, in addition to conducting a comprehensive patient and facility tracer, the accreditation team will focus on the following QI initiatives:

  • medication management, e.g. patient-specific orders, preparation, storage
  • allergy management
  • surgical safety checklist compliance
  • post-anesthesia discharge scoring system
  • anesthesia equipment reprocessing
  • obstructive sleep apnea screening and post-anesthesia care
  • hand hygiene education and compliance auditing

The Non-Hospital Medical and Surgical Facilities Program requires private facilities to maintain high standards of practice equal to or exceeding public hospitals. The program establishes accreditation and performance standards, procedures and guidelines to ensure the delivery of high quality health services. The 700 physicians who work in private facilities across the province must be granted privileges by the College.