Qmentum International - Emergency Department

3/25/2018 Qmentum International
Qmentum International
Emergency Department
Standards
https://www.qmentuminternational.org/LAPStandardOnline/stdQIntl.aspx?Std=bnxt5eJx+rSRhcG/s81BWIUxhJGKLHuSe3+4xDwVowh4oDPxY7GQynPJizDWE6OaRx
The Emergency Department standards are intended for organizations that provide initial treatment to clients with a broad spectrum of illnesses
and injuries, some of which may be life-threatening and requiring immediate attention. The Emergency Department (ED) is located within an acute
care facility, and may also be known as the emergency room (ER), emergency ward (EW), accident & emergency (A&E) department or casualty
department.
The Emergency Department standards help organizations assess quality at the point of service delivery. They are based upon five key elements of
service excellence: clinical leadership, people, process, information, and performance. The Emergency Department Services standards contain
the following subsections:
· Investing in Emergency Department Services
· Having the Right People
· Delivering Quality Emergency Department Services
· Maintaining Accessible and Efficient Clinical Information Systems
· Having a Positive Impact on Outcomes
Accreditation Program
Accreditation Program has three accreditation levels: Gold, Platinum, and Diamond. Each level creates consistency and efficiency in service
delivery through standardized processes, providing international health organizations with a tailored, step-by-step approach to accreditation and
quality improvement.
· Gold addresses structures and processes linked to foundational elements of safety and quality improvement.
· Platinum builds on these elements of quality and safety, while also emphasizing client-centred care and client and staff involvement
in decision making.
· Diamond focuses on achieving quality by monitoring outcomes, using evidence and best practice to improve services, and
benchmarking with peer organizations to drive system-level improvements.
For all levels, client organizations undergo an on-site survey every three years where they are evaluated against the standards.
The Structure of the Standards
A set of standards is divided into sections that address different aspects of quality service such as investment in services, staffing, service
provision, information systems, and quality improvement. Each section consists of related standards, criteria, and guidelines.
1.0 The standard. A goal statement under which associated criteria are grouped.
1.1 The criterion. A measurable element that defines what is required to achieve the standard. Each criterion is assigned a level of Gold,
Platinum, or Diamond and linked to one of eight quality dimensions, identified by an icon: accessibility, client-centred services, continuity of
services, effectiveness, efficiency, population focus, safety, and worklife. Surveyors rate each criterion during the on-site survey.
Some criteria are identified as Required Organizational Practices (ROPs). An ROP is as an essential practice that organizations should have in
place to enhance patient and client safety and minimize risk.
Guidelines: Some criteria include guidelines that provide additional information and/or suggestions on how to comply with the criterion.
Glossary:
Indicator: A single, standardized measure, expressed in quantitative terms, that captures a key dimension of individual or population health, or
health service performance. An indicator may measure an aspect of a process or a health or service outcome. Indicators need to have a definition,
a numerator, a denominator, inclusion and exclusion criteria, and a time period. Tracking indicators data over time identifies successful practices
or areas requiring improvement; indicator data is used to inform the development of quality improvement activities. Types of indicators include:
structure measures, process measures, outcome measures and balancing measures.
References:
Association of Public Health Observatories (APHO). (2008). The Good Indicators Guide: Understanding how to use and choose indicators. NHS
Institute for Innovation and Improvement.
BC Patient Safety & Quality Council. (2010) Measurement strategies for improving the quality of care: A review of best practice. Vancouver BC.
Centers for Disease Control and Prevention (2003). Prevention Works: CDC Strategies for a Heart-Healthy and Stroke-Free America. Atlanta, GA:
U.S. Department of Health and Human Services. Available online: http://www.cdc.gov/DHDSP/library/prevention_works/index.htm.
Institute for Healthcare Improvement (IHI) (2012). How to Improve. Available online:
http://www.ihi.org/knowledge/Pages/HowtoImprove/default.aspx.
Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP (2009). The Improvement Guide: A Practical Approach to Enhancing Organizational
Performance (2nd edition). San Francisco: Jossey-Bass Publishers.
Lloyd R. (2004) Quality healthcare: A guide to developing and using indicators. Sudbury MA. Jones and Bartlett Publishers.
Raleigh VS, Foot C. (2010). Getting the Measure of Quality: Opportunities and Challenges. London: The King's Fund.
Safer Healthcare Now! (2011). Improvement Frameworks Getting Started Kit. Canadian Patient Safety Institute. Available online:
www.saferhealthcarenow.ca.
Safer Healthcare Now! Patient Safety Metrics: Measuring to Reduce Harm. Available online: <https://shn.med.utoronto.ca/metrics/Login.aspx>.
INVESTING IN EMERGENCY DEPARTMENT SERVICES

1.0 The team develops its emergency department services to meet the
needs of clients, families, and referring organizations.
1.1 The organization has a current license to offer emergency department

services.
Gold
Effectiveness
1.2 The organization's license clearly states which emergency department

services it provides, and can be viewed by all clients, families, visitors, and
staff and service providers. Gold
Effectiveness
1.3 The organization's policies and procedures for delivering emergency

department services comply with applicable laws and regulations.
Gold
Effectiveness
1.4 The team collects information about its clients and the community.
Platinum
Population Focus
Guidelines
Information includes the types of clients served by the organization and their
service needs, and trends that could have an impact on the community and
its health service needs. Service needs are influenced by health status,
capacities, risks, and determinants of health such as lifestyle, education, and
housing. Information can come from internal and external sources such as
the Canadian Institute for Health Information (CIHI), census data, end of
service planning reports, wait list data, and community needs assessments.
If it is not within a team's mandate to collect information, it knows how to

access and use information that is available.
1.5 The team collects information about its referring organizations and providers.
Platinum
Population Focus
Guidelines
Emergency departments work with many different organizations, partners,

and care providers including primary care providers, clinics, community-
based organizations, long-term care, home care, EMS, and law enforcement.
To help provide comprehensive care, the team collects information about the
organizations and providers with which it works. Information may vary
depending on the type of organization or provider and the frequency of
referral.
1.6 The team uses the information it collects about clients and the community to
define the scope of its services and set priorities when multiple service needs
are identified.
Platinum
Population Focus
Guidelines
When defining the scope of its services, the team considers the resources
that are available and those that are needed for urban, rural or remote
centres or clients with special considerations (e.g., screening elderly clients
for cognition, mobility, home safety) and establishes processes to avoid
inappropriate admissions.
1.7 The team's scope of services is aligned with the organization's strategic
direction.
Platinum
Effectiveness
Guidelines
Expectations regarding the team's scope of services may be outlined in

provincial or territorial legislation or strategies.
1.8 The team works together to develop goals and objectives.
Platinum
Effectiveness
Guidelines
Team members have input into the development of team goals and
objectives. Community partners, clients, and families may also be involved in
developing team goals and objectives.
The team's goals and objectives provide the foundation for delivering
services.
1.9 The team establishes specific goals and objectives regarding wait times,
length of stay (LOS) in the emergency department, client diversion to other
facilities, and number of clients who leave without being seen. Diamond
Effectiveness
Guidelines
The team's goals regarding wait times include time of arrival to EMS
offloading, time of arrival to physician consultation, wait times for diagnostic
imaging and specialty consultation, and time from physician consultation to
decision to admit/discharge.
The team works together, as well as with internal and external partners, to
establish goals based on the individual circumstances of their organization.
This may also include provincial/territorial or regional objectives.
1.10 The team works with the organization's leaders to define the role of the
emergency department in the organization's all-hazard disaster and
emergency response plan. Gold
Safety
Guidelines
The plan clearly defines the role of the emergency department and is
integrated with the organization's all-hazard disaster and emergency
response plan.
1.11 The team collaborates with its partners to develop resource-sharing
arrangements to offer safe and effective services for each client and family.
Platinum
Effectiveness
Guidelines
Partners include those within and external to the organization.
1.12 The team regularly reviews its services and makes changes as needed.
Diamond
Effectiveness
Guidelines
The team reviews the appropriateness of its services as well as the need for
new services.
2.0 The team has access to the resources it needs to deliver services in
the emergency department.
2.1 The team has the right number and mix of staff needed to provide consistent
quality of services for clients and referring organizations on a twenty-four
hour basis. Platinum
Efficiency
Guidelines
The number and mix of staff needed may be based on a number of factors,
including the types of services provided; the number of beds or locations
where services are provided; the types of clients admitted to the unit and
their level of acuity; the number of shifts throughout the day and typical work
hours; and fluctuations in terms of demand for services throughout the day.
2.2 When delivering emergency department services, the team has access to
equipment and supplies appropriate to the needs of the community or
catchment area. Gold
Effectiveness
2.3 The team has the workspace it needs to deliver effective services in the
emergency department.
Gold
Effectiveness
2.4 The team has access to seclusion rooms and/or private and secure areas for
clients.
Platinum
Safety
Guidelines
Seclusion rooms and/or private and secure areas are only used as a short-
term intervention to protect the safety of the client or others in the emergency
department. Seclusion rooms and/or private and secure areas may be used
when clients who present to the emergency department are verbally or
physically aggressive, are experiencing high levels of anxiety, are in distress,
are in danger of self harm, or are dealing with circumstances that require an
increased level of security and/or privacy (e.g., they have been brought to
the emergency department by law enforcement).
Seclusion rooms and the private and secure areas are designed for that
purpose and adhere to relevant guidelines. They are comfortable, safe, and
are monitored by the team to ensure client safety.
2.5 The team has access to equipment and supplies that are appropriate for
pediatric clients.
Gold
Safety
Guidelines
Standard sized equipment and supplies are normally inappropriate for

pediatric clients. Neonatal and pediatric sizes of all relevant equipment and
supplies may be provided in the emergency department or shared with other
inpatient services (e.g., pediatric ward, nursery).
The Canadian Association of Emergency Physicians also provides a list of

recommended minimum equipment for emergency departments in rural
communities.
2.6 The team ensures that emergency and advanced resuscitation equipment,
supplies, and materials are available in the room where procedural sedation
is administered. Gold
Safety
3.0 The team manages the client flow throughout the emergency
department.
3.1 The team works in collaboration with organizational leaders to address and
manage client flow throughout the organization.
Gold
Effectiveness
Guidelines
The team uses the information it collects through monitoring and evaluating
trends in the emergency department to identify areas for improvement, and
advocates for resources (e.g., financial, support for change) with
organizational leaders. Strategies to address overcrowding in the emergency
department may include assessing and releasing select clients by
Emergency Medical Services (EMS) to community health services or primary
care, proactive communication about the use and access to resources in the
community, improved information technology to assist with client distribution,
a process at triage for the efficient offload of EMS clients, and transfer of
care agreements.
3.2 The team works in collaboration with organizational leaders to take a

proactive approach to prevent and manage overcrowding in the emergency
department. Platinum
Accessibility
Guidelines
A proactive approach to managing overcrowding in the emergency

department includes monitoring trends and developing a strategy to prevent
and address overcrowding. The team works to anticipate times of
overcrowding and uses strategies to manage overcrowding in a safe and
timely way. This may include assigning staff during times of the day when an
increase in requests for services typically occurs.
3.3 The team works with other services and teams within the organization to
coordinate timely access for clients.
Platinum
Effectiveness
Guidelines
Other services or teams include medicine services, critical care, surgical

services, ambulatory services, diagnostic imaging, laboratory services,
cardiac imaging, and pharmacy services.
3.4 The team provides access to the emergency department 24 hours a day,
seven days a week.
Gold
Accessibility
Guidelines
The team works with other providers, organizations, and the community to
ensure that emergency services are available from other locations or groups
when there is a high volume of emergencies.
3.5 The team identifies and addresses barriers within the emergency department
that impede clients, families, providers, and referring organizations from
accessing services. Platinum
Accessibility
Guidelines
Barriers to access include: overcrowding as a result of breakdowns in client

flow and transfer of clients to inpatient units; physical and language barriers;
a lack of or an inefficient over-capacity protocol; overcrowding as a result of
a high volume of clients presenting in the emergency department;
transportation; ambulance offload delays; ambulance diversion from another
organization; and a lack of inpatient beds.
3.6 The team works with its partners to provide comprehensive emergency
services.
Continuity of Gold
Services
Guidelines
Partners include other emergency health partners and other referral or

transfer sources. The team has established connections with partners and
communicates regularly to anticipate requests for service and facilitate
smooth transitions in care. Other emergency health service providers may
include local ambulance service operators and dispatchers, fire departments,
and community groups.
Partners outside of emergency health include referring areas of the

organization as well as primary care. The team works with these
organizations to ensure smooth and safe transitions in care.
3.7 The team has established procedures with EMS providers for transport of
high-risk clients.
Platinum
Safety
Guidelines
Efficient transportation to the appropriate organization ensures that clients

are receiving services in the appropriate organization and improves client
outcomes. The organization works with partners to establish procedures for
client transport. This includes providing training and information to partners
about the services provided in the organization, establishing protocols, early
communication of high-risk clients or suspected conditions (e.g. trauma,
stroke, head injury, spinal cord injury), bypass of smaller centres, use of air
ambulance services, and use of specific screening tools.
3.8 The team follows standardized processes and procedures to coordinate

timely inter-facility client transfers and transfers to other teams within the
Diamond
organization.
Effectiveness
Guidelines
This may include transfer to a higher level of care or specialized services

within an organization and may be established by the organization or
triggered by specific conditions (e.g., stroke, suspected head injury,
suspected spinal cord injury, or suspected acute coronary syndrome).
Processes to improve client flow to other facilities and within the organization
may include a client flow strategy or diagram, a time series model to predict
inpatient resource requirements generated by admission to the emergency
department, or an emergency department full capacity protocol to facilitate
the admission of clients held in the emergency department awaiting bed
assignment.
3.9 The team participates in discharge planning and provides input about clients
who are being referred to other health care services and programs.
Platinum
Accessibility
Guidelines
Other health care services and programs may include community-based

health care or social services programs.
3.10 The team has established protocols to identify and manage overcrowding
and surges in the emergency department.
Gold
Accessibility
Guidelines
The team has and follows protocols for overcrowding and surges. Protocols
include information on when protocols are triggered (e.g., team to client ratio
or threshold for client wait times), staffing protocols, when to contact other
teams within the organization, and when to contact external partners.
Protocols are developed in partnership with other teams and community

partners and align with the organization's disaster and emergency
preparedness plan.
3.11 The team follows protocols to move clients elsewhere within the organization
during times of overcrowding.
Gold
Safety
Guidelines
In addition to limiting access to timely and appropriate care, overcrowding is

a safety risk. In the event of overcrowding, the team follows protocols to
improve inpatient utilization and move the right client to the right bed within
the right time frame using mutually-agreed upon transfers of care with other
parts of the organization. The team also identifies clients for an alternate
level of care (ALC) including chronic care, chronic complex care, transition
care, respite care, and palliative care, and begins the process to transfer
ALC clients.
3.12 The team follows established protocols to manage clients when access to
inpatient beds is blocked.
Platinum
Accessibility
Guidelines
Protocols will vary depending on the type and size of the organization,
community served, and other resources available to clients. The organization
may explore other referral or service options, e.g., transferring clients to
another hospital or determining if a client is willing to remain in the
emergency department if discharge to other health care services and
programs is not feasible.
3.13 The team follows organizational protocols to manage overcrowding and

surges before requesting aid from alternative health care sites or diverting
ambulances. Platinum
Accessibility
Guidelines
Requesting aid from alternative health care sites may be an option in some
areas when an organization is over capacity. The organization has and
follows protocols for when alternative aid and/or ambulance diversion should
be accessed.
Often protocols are established by the region where the organization is

located.
3.14 The team has an emergency preparedness plan that describes the role of the
emergency department and resources available to manage emergencies and
disasters. Gold
Safety
Guidelines
The team's plan is in line with the organization's overall plan for emergency
and disaster preparedness.
HAVING THE RIGHT PEOPLE

4.0 The team uses a multidisciplinary approach to deliver emergency
department services.
4.1 The organization identifies a multidisciplinary team to deliver emergency

Continuity of Gold
Services
Guidelines
The interdisciplinary team includes people with different roles and from
various disciplines. Depending on the needs of clients and families, the team
may include primary care staff including physicians, nurses, and nurse
practitioners; EMS staff; trauma specialists; social workers; respite care
workers; respiratory therapists; care planners; administrators; translators;
security staff; or representatives from community partner organizations.
4.2 The team leaders are certified medical doctors.
Gold
Effectiveness
4.3 The multidisciplinary team includes consultants and referring medical

professionals who work with staff and service providers in the emergency
department to coordinate services or transfers. Gold
Efficiency
4.4 Team members have position profiles that define roles, responsibilities, and
scope of practice.
Gold
Worklife
Guidelines
Position profiles include a position summary, specify qualifications and

minimum requirements for the position, state the nature and scope of the
work, and clarify reporting relationships.
Role clarity is essential in promoting client and staff safety, as well as a

positive work environment. Understanding roles and responsibilities, and
being able to work to one's full scope of practice helps create meaning and
purpose for individuals.
4.5 The multidisciplinary team communicates regularly to coordinate services,

roles, and responsibilities.
Platinum
Safety
Guidelines
Miscommunication or a lack of communication among interdisciplinary team

members often compromises client safety. Making accurate and timely
communication a priority promotes continuity of care and helps prevent
adverse events.
Communication mechanisms can include meetings, teleconferences, or

virtual technologies such as telehealth or webconferencing, and may involve
the client, family, caregiver, or client advocate.
4.6 The multidisciplinary team follows a formal process to regularly evaluate its
functioning, identify priorities for action, and make improvements.
Diamond
Effectiveness
Guidelines
The team's process to evaluate its functioning includes a review of its

services, processes and outcomes. This may include administering a team
functioning or climate questionnaire to team members to stimulate
discussion about areas for improvement.
The team evaluates its functioning at least annually, and whenever there is a
significant change in the structure of the team.
5.0 Team members are educated, trained, qualified, and competent.
5.1 The team leaders follow set criteria to recruit and select team members
based on their qualifications, experience, and fit with the team.
Platinum
Worklife
5.2 Each team member has the necessary credentials or licenses from the
appropriate professional college or association.
Gold
Effectiveness
Guidelines
For example, physicians should be licensed by the applicable regulatory

authorities and certified by the appropriate college. Requirements for other
health professionals, including nurses and other allied health providers, will
differ by profession and jurisdiction.
The qualifications of team members who are not regulated by professional

bodies, i.e. unregulated health providers such as personal support workers
and administrative staff, are also verified.
The team has a process to verify that team member credentials or licenses
are appropriate and up-to-date.
5.3 The team orients new team members about their roles and responsibilities,
team goals and objectives, and the organization as a whole.
Gold
Effectiveness
Guidelines
The orientation program covers the organization's mission, vision, and

values; the team's mandate, goals, and objectives; roles, responsibilities,
and expectations regarding performance; policies and procedures, including
confidentiality; initiatives that support worklife balance; and the organization's
approach to integrated quality management (e.g., quality improvement, risk
management, and utilization management/efficient use of resources).
5.4 The team orients new team members to the unique work environment in the
emergency department.
Gold
Effectiveness
Guidelines
Orientation includes the specific nature of the emergency department; the

triage process; the value of linking with team members beyond the
emergency department (e.g., EMS, consultants, trauma services, and
alternative levels of care); emergency disaster planning; protocols to address
high volume and surges in the emergency department; and the process to
address wait times.
Orientation also includes how risks (e.g., potentially violent or aggressive

clients, hazardous materials or potentially contaminated clients or items) are
managed in the emergency department and when to contact law
enforcement or access security services.
5.5 New team members are trained on the safe use, storage, and operation of
equipment, devices, and supplies used in delivering emergency department
services, as well as preventive maintenance and what to do in case of Gold
Safety breakdown.
Guidelines
The training includes the safe use, storage, and operation of common
equipment, devices, and supplies commonly used in the emergency
department as well as the safe use, storage, and operation of specialized
equipment as appropriate (e.g., cardiac monitoring equipment, ventilators,
CPAP and BiPAP machines, and fluid warmers).
5.6 REQUIRED ORGANIZATIONAL PRACTICE: The organization provides

ongoing, effective training for service providers on all infusion pumps.
Platinum
Safety
Guidelines
The more types of infusion pumps there are within an organization, the more
chance there is for serious error. To minimize risk staff and service providers
receive ongoing, effective training on infusion pumps, covering client clinical
needs, staff competency, staff continuity, infusion pump technology, and the
location of the pumps (e.g. hospital, community, home). This training is
particularly important given that many service providers often work at more
than one health service organization, meaning they need to be competent in
using many different types of infusion pumps.
Organizations are also encouraged to standardize infusion pumps to the

greatest possible extent.
Test(s) for Compliance

There is documented evidence of ongoing, effective training on
5.6.1
infusion pumps.
5.7 The team receives education and training specific to the delivery of
emergency department services.
Gold
Worklife
Guidelines
Training may include triage policies, process, and documentation; decision

support software for Canadian Triage and Acuity Scale (CTAS); managing
violence and security breaches; care maps; assessing clients for physical,
sexual or psychological abuse; end of life issues, including advance
directives, and do not resuscitate (DNR); and use of least restraint policies.
An interdisciplinary approach to education and training may be used to

encourage collaboration across disciplines.
5.8 The organization trains the team on how to prevent workplace violence.
Gold
Safety
Guidelines
Violence includes abuse, aggression, threats, and assaults. Workplace

violence includes acts committed by clients (or their families) or other staff
and service providers, domestic violence in the workplace, and random
violence that occurs as a result of a criminal act.
The training and education addresses the following core competencies:

identifying triggers; recognizing signs of agitation and aggression;
responding to and managing violence (e.g., de-escalation techniques,
conflict resolution and mediation, and self-defense); communication; and
change management.
5.9 The organization trains the team on how to report incidents of workplace
violence.
Platinum
Worklife
Guidelines
Reporting includes perceived, potential, or actual incidents of violence.
5.10 The team receives education and support to work with clients with mental
health and addictions.
Platinum
Worklife
Guidelines
The team receives education and support on issues and risks related to
mental health and addictions. Education promotes effective and equitable
care for all clients who present in the emergency department.
Education includes working with clients who have a history of mental health
and addictions, have an increased level of anxiety, are at risk of or are
exhibiting aggressive behaviour, are at risk of self harm, are not in the
emergency department willingly, and who may be uncooperative. Education
also includes organizational policies for dealing with aggressive clients or
clients who are presenting a danger to themselves and/or others, when to
use seclusion, and monitoring clients who are in seclusion.
5.11 New team members receive cultural competency training to provide effective
services to all clients.
Platinum
Effectiveness
Guidelines
Cultural competency is a set of skills that allows team members to increase

their knowledge of cultural differences. Cultural differences can include
country of origin, language, education, spiritual traditions, family traditions,
diet and nutrition, traditional medical practices, and attitudes about illness
and death. Understanding a client's cultural background assists in creating a
care plan care that meets the individual needs and expectations of clients.
5.12 The team receives training specific to providing emergency health services to
pediatric clients.
Platinum
Worklife
Guidelines
Training addresses the unique needs of pediatric clients including

developmental stages, pediatric reference values, interaction with families,
informed consent, Pediatrics Canadian Triage and Acuity Scale (P-CTAS),
resuscitation and life support for infants and children, weight-based dose
adjustment of medications, safe use of pediatric medical equipment, pain
management, care protocols for common pediatric conditions, pediatric
radiology protocols, and children and youth maltreatment.
5.13 The team monitors and meets each team member's ongoing education,
training, and development needs.
Diamond
Worklife
Guidelines
The process to monitor and meet each team member's ongoing learning
needs may include performance evaluations, or regular assessment of team
needs. It also identifies when specific training is required, such as when new
technology, equipment, or skills are introduced, or after a team member has
been away for an extended period of time.
5.14 Team leaders regularly evaluate and document each team member's
performance in an objective, interactive, and constructive way.
Diamond
Effectiveness
Guidelines
Team leaders use the organization's established process to evaluate each

team member's performance.
When evaluating performance, team leaders review the individual's ability to

carry out responsibilities, professionalism, and consider the individual's
strengths, areas for improvement, and contributions regarding client safety,
worklife, and other areas described in the position profile. They may also
seek client or peer input.
A performance evaluation is usually done before the probationary program is

completed and annually thereafter or as defined by the organization. An
evaluation may also be completed following periods of retraining (e.g., when
new technology, equipment, or skills are introduced).
6.0 Team leaders promote the team's well-being and worklife balance.
6.1 The organization has defined criteria that are used to assign team members
to clients and other responsibilities in a fair and equitable manner.
Platinum
Worklife
Guidelines
The criteria are based on accepted standards of practice, legal

requirements, knowledge, experience and other qualifications, volume or
complexity of the caseload, changes in workload, and client safety and
needs.
This process also applies to students and volunteers, with adjustments made
as required.
6.2 The team assesses workload and reassigns team members as required
during periods of high volume and surges in the emergency department.
Gold
Safety
Guidelines
The process to assess workload and reassign team members during periods
of high volume and surges is monitored, and the data are used to develop
criteria to ensure client safety as well as fairness and equity in workload.
6.3 The team has a process for identifying and reducing risks to team members
while delivering emergency department services.
Gold
Safety
Guidelines
Common risks may include aggressive and violent behaviour or security

breaches in the emergency department and subsequent risk to clients,
families, and staff; infectious disease; hazardous materials; and using unsafe
equipment. The team works with their leaders and the organization to reduce
risks. Team members feel comfortable raising concerns about their safety
when delivering emergency department services.
6.4 Team members have input on work and job design, including the definition of
roles and responsibilities, and case assignments, where appropriate.
Diamond
Worklife
Guidelines
Job design refers to how a group of tasks, or an entire job, is organized. Job
design addresses all factors that affect the work, including job rotation, work
breaks, and working hours. Effective job design helps staff manage time,
fatigue, stress, and worklife balance.
6.5 Team leaders, with input from the team, regularly evaluate the effectiveness
of staffing and use the information to make improvements.
Diamond
Effectiveness
Guidelines
The evaluation covers job design, position profiles, practice roles, and case
assignments.
6.6 The team has a fair and objective process to recognize team members for
their contributions.
Diamond
Worklife
Guidelines
Recognition activities may be individual, such as service awards based on

years of service, or team-based, such as team activities.
6.7 The team's leaders monitor each team member's fatigue and work to manage
stress and safety risks.
Diamond
Safety
Guidelines
The team's leaders can monitor hour worked, overtime, or the incident of
adverse events to monitor fatigue and stress. In the workplace, stress and
fatigue can result from scheduling and staffing issues, or environmental
distractions such as noise. The team's leaders can modify these factors to
manage stress and safety risks.
6.8 Team members have access to healthy workplace strategies to help them to
manage their own health.
Diamond
Worklife
Guidelines
Healthy workplace strategies may be offered at the team level or
organization wide. They include education about health and determinants of
health; programs to help manage stress, reduce weight, and quit smoking;
and initiatives to encourage healthy lifestyles, e.g. incentives for gym
memberships and exercise, or lunch-time sessions on healthy eating.
DELIVERING QUALITY EMERGENCY DEPARTMENT SERVICES

7.0 The team coordinates timely access to services for current and
potential clients, families, service providers, and referring
organizations.
7.1 The organization ensures that the entrance(s) to the emergency department
are clearly marked and accessible.
Gold
Accessibility
Guidelines
The emergency department is identified through appropriate signage. This

may include “H” signs posted on major roadways; clear directions to the
emergency department and hospital for ambulatory clients, emergency
vehicles, and client vehicles; signs inside the hospital indicating where to find
the emergency department or the 24-hour on-call physician; and clearly
marked helipads for hospitals that use air emergency medical services.
7.2 The team evaluates all clients who present at the emergency department.
Gold
Accessibility
Guidelines
The evaluation process includes a method to prioritize or triage clients by

level of urgency and relocate clients with less urgent needs to waiting rooms
or other areas or levels of care such as urgent care, clinics or for particular
client symptoms, point-of-care testing, or rapid diagnostics.
7.3 A nurse or other medical professional offloads clients from EMS and
conducts and documents timely initial assessments.
Gold
Effectiveness
Guidelines
Typically offloading is completed by an emergency department nurse,

however this can also be done by other medical personnel such as a
paramedic.
7.4 The team works with EMS to transfer pertinent client information.
Gold
Efficiency
Guidelines
The effective transfer of client information includes providing information to

EMS as well as obtaining comprehensive client information when the client
arrives at the organization. Pre-hospital information may include proposed
triage categories or priority categories; basic or advanced assessment;
medical directives; client-specific orders; client history, records, progress
notes, or verbal reports; telephone advice; medico-legal issues such as
police cases, e.g. indications of domestic violence and abuse; animal bites;
consent to treatment; involuntary clients; client refusals; withdrawal of life
support; clients who are dead on arrival; confidentiality of information; safety
and security of client identification, valuables, and belongings.
8.0 The team triages clients in the emergency department in a timely way.
8.1 The team uses a standardized process to conduct a triage assessment.
Platinum
Effectiveness
Guidelines
Examples of triage tools that are currently in widespread use include: the
Manchester Triage Scale, the Canadian Triage and Acuity Score, the
Australian Triage Score, and the Emergency Severity Index.
8.2 The team uses an appropriate standardized process to conduct a triage

assessment of pediatric clients.
Platinum
Effectiveness
8.3 The team completes and documents a timely triage assessment for each
client within established timelines.
Gold
Effectiveness
Guidelines
Clients receive a complete triage assessment regardless of how they arrive

in the emergency department.
8.4 The team conducts a triage assessment for each pediatric client within
established timelines.
Gold
Effectiveness
8.5 After triage, the team follows set criteria and gathers input from the client's
other service providers to identify immediate and urgent needs and decide on
priorities of service. Platinum
Effectiveness
Guidelines
Teams may label this process registration, admission, intake, pre-admission,

or screening. Immediate and urgent needs may include: an older adult's age-
related changes, (e.g., atypical presentation, wandering); clients who present
with repeat injuries; clients who present with circumstances that may require
intervention of law enforcement (e.g., indications of domestic violence and
abuse, indications of violent crimes, gunshot wounds, or homicide). In some
cases this process is conducted at the same time as triage.
The process is adjusted for clients and families with differing needs such as
language, culture, level of understanding, lifestyles, and disability.
8.6 After the initial triage assessment, the team advises clients who are waiting
for service which team member to contact if their condition changes.
Client-centred Gold
Services
8.7 The team has ongoing communication with clients who are waiting for
services.
Client-centred Gold
Services
8.8 The team monitors possible deterioration of condition for clients waiting in the
emergency department and reassesses clients as appropriate.
Gold
Effectiveness
Guidelines
Clients who initially appear stable may deteriorate as illnesses progress. The
team re-assesses all clients (e.g., clients in hallways, waiting rooms,
ambulance bays) according to policy, and staff and service provider
responsibilities for re-assessment are defined. The team's process includes
measuring the timeliness of the re-assessments and setting targets based
on CTAS re-assessment guidelines.
Where possible the team works in a way that allows them to continually
monitor client waiting areas. Where this is not possible the team develops
and follows a process to regularly monitor, assess, and document clients
who are waiting in the emergency department.
9.0 The team efficiently assesses clients who present to the emergency
department.
9.1 Following triage, the team completes a timely assessment for each client.
Gold
Accessibility
Guidelines
The team is encouraged to set and track timeframes for completing the initial
assessment.
9.2 The team asks the client about his or her health history when determining
service needs.
Client-centred Platinum
Services
Guidelines
When prioritizing and managing client and family services, the team uses
information provided by the client as well as information from other health
service providers such as physicians, paramedics, Emergency Medical
Technicians, Emergency Medical Responders, nurses, nurse practitioners,
and social workers.
9.3 REQUIRED ORGANIZATIONAL PRACTICE: The team reconciles the client's

medications following triage, with the involvement of the client.
Diamond
Safety
Guidelines
Medication reconciliation is a way to collect and communicate accurate

information about client medication, including over-the-counter medications,
vitamins, and supplements. Poor communication about medication at
transition points can cause errors and adverse events.
Medication reconciliation is a shared responsibility which must involve the
client or family. Liaison with the primary care provider and community
pharmacist may be required.

The organization has a documented protocol to reconcile client
9.3.1
medications following triage.
The protocol includes a single documented, comprehensive list

of the most accurate and current medications the client has
9.3.2
been taking prior to admission to the organization (best possible
medication history).
The protocol includes a review of this prior-to-admission

9.3.3 medication list with the list of new medications ordered by the
organization.
The protocol requires documentation that the two lists have

been compared; differences have been identified, discussed,
9.3.4
and resolved; and appropriate modifications to the new
medications have been made where necessary.
The protocol makes it clear that medication reconciliation is a

9.3.5
shared responsibility.
9.4 The team assesses the client's physical and psychosocial health.
Gold
Effectiveness
Guidelines
Building on information collected from the triage process the team works with
the client to assess health using various sources such as information
collected from emergency medical staff and EHR. Elements of physical
health include medical history, allergies, medication profile, health status;
personal safety and the home environment, including exposure to physical,
psychological or sexual abuse; and nutritional status and special dietary
needs. Elements of psychosocial health include functional and emotional
status, including client's communication and self-care abilities; mental health
status, including personality and behavioural characteristics; socioeconomic
situation; spiritual orientation; and cultural beliefs.
9.5 The assessment includes a discussion with the client about pain
management options and preferences.
Platinum
Effectiveness
Guidelines
The team member discusses appropriate options with the client and gives
the client an opportunity to select a preferred option for pain management.
Strategies to manage pain may include analgesics, including opioids and
adjuvants when needed, along with physical, behavioural, and psychological
interventions. The team consults with experts and uses research and
evidence to understand the best ways to manage pain.
The team also gives the client information about how to manage pain
following discharge.
9.6 REQUIRED ORGANIZATIONAL PRACTICE: The team assesses and

monitors clients for risk of suicide.
Platinum
Safety
Guidelines
Suicide is a global health concern. In 2012, there were over 800 000 suicide
deaths, representing the second leading cause of death globally among
young people 15-29 years of age. Risk assessment can help prevent suicide
through early recognition of the signs of suicidal thinking and appropriate
intervention.

9.6.1 The team identifies clients at risk of suicide.
The team assesses each client for risk of suicide at regular

9.6.2
intervals, or as needs change.
The team addresses the immediate safety needs of clients who

9.6.3
are identified as being at risk of suicide.
The team identifies treatment and monitoring strategies to

9.6.4
ensure client safety.
The team documents the implementation of the treatment and

9.6.5
monitoring strategies in the client's health record.
9.7 The team has priority access to diagnostic services and laboratory testing
and results 24 hours a day, 7 days a week.
Gold
Effectiveness
Guidelines
Based on the organization's resources, 24-hour access to diagnostic and

laboratory testing and results may be available on an on-call basis for life-
threatening situations only. The emergency department team works with
diagnostic and laboratory services to ensure effective access that prioritizes
client needs while recognizing organizational demands (e.g., hours of
operation, staffing, and when call-in processes are initiated).
Access to diagnostic and laboratory services may be on-site or through

partner organizations. Where these services are not on-site the
organizations has an established process to facilitate access.
The team works with diagnostic and laboratory services to establish

protocols for access including which tests and conditions take priority based
on acuity level.
9.8 The team uses evidence-based protocols to select diagnostic imaging

services for pediatric clients.
Gold
Effectiveness
Guidelines
Inappropriate use of diagnostic imaging may increase costs and expose

pediatric clients to unnecessary radiation. The team is encouraged to
collaborate with diagnostic imaging services to develop evidence-based
radiology protocols.
9.9 The team has timely access to urgent medications and pharmacy staff 24
hours a day, 7 days a week.
Gold
Safety
Guidelines
The team may have access to pharmacy staff within their organization or
through partner organizations. Consult may be conducted through
telemedicine or be done on an on-call basis. Where consult services are not
on-site the organization has an established process to facilitate access.
9.10 The team has priority access to consultation services 24 hours a day, 7 days
a week.
Gold
Effectiveness
Guidelines
The team may consult with specialists or allied health professionals within
their organization or through partner organizations. Consult may be
conducted through telemedicine or be done on an on-call basis. Where
consult services are not on-site the organization has an established process
to facilitate access.
The team works with other teams to establish protocols for accessing
consultation services and conditions that take priority based on acuity level.
9.11 The team has timely access to specialists with expertise in pediatric health.
Platinum
Effectiveness
Guidelines
Specialists with expertise in pediatric health may include pediatricians,

pediatric emergency physicians, pediatric radiologists, and pediatric
surgeons. Access to specialists can either be provided on-site or using
virtual technologies such as telehealth.
9.12 The team follows a process for team members to communicate and validate
client diagnoses when there is discrepancy between the initial diagnosis and
diagnostic imaging or laboratory results. Diamond
Safety
Guidelines
The team's process to communicate changes in diagnosis or information to

clients when a discrepancy, change, or error is identified is established with
other teams. The process includes who is responsible for contacting the
client and/or family in a timely way and next steps.
9.13 The team regularly reviews the client assessment and updates it if the client's
health status changes.
Gold
Effectiveness
Guidelines
Delays or failures to report a change in health status, in particular

deterioration in a client's condition, are significant barriers to safe and
effective care and services. Changes in the client's health status are
documented accurately and quickly, and communicated to all team
members.
10.0 The team identifies and refers potential organ and tissue donors in a
timely and effective manner.
10.1 The organization has established protocols and policies on organ and tissue
donation.
Gold
Efficiency
Guidelines
Policies include identification of potential donors, approaching the family of

potential donors, checking the provincial donor registry, and working with the
Organ Procurement Organization (OPO).
10.2 The organization has a policy on neurological determination of death (NDD).
Gold
Efficiency
Guidelines
The policy on NDD includes the definition of and testing required to

determine NDD, who is qualified to determine NDD, and ethical frameworks
around NDD (e.g., physicians who determine NDD must be independent of
the procurement and transplant process).
10.3 The organization has a policy to transfer potential organ donors to another
level of care once they have been identified.
Gold
Efficiency
Guidelines
It is important that potential organ donors are moved to another level of care
to facilitate client access to the Emergency Department. The team works
with the other areas of care, (e.g., critical care, organ recovery centre, or
tissue recovery team) to establish time frames for the transfer of potential
organ and tissue donors. The emergency department team works with other
areas of care in the organization to ensure smooth and effective transfers in
care.
10.4 The organization has established clinical referral triggers to identify potential
organ and tissue donors.
Gold
Effectiveness
Guidelines
The organization establishes clinical referral triggers that define criteria for
imminent death. For organ donation, these clinical triggers address clients
requiring mechanical ventilation; having clinical findings consistent with a
score on the Glasgow Coma Scale less than or equal to an agreed-upon
threshold; being evaluated for a diagnosis of neurological death; having
withdrawal of life-sustaining therapies ordered by a physician; or lacking of
brain stem reflexes. For tissue donation, these triggers address clients with
cardiac death who are under 85 years of age.
10.5 The team receives training and education on organ and tissue donation and
the role of the organization and the Emergency Department.
Platinum
Effectiveness
Guidelines
The emergency department team is trained regarding its role in organ and
tissue donation. The role of the team will vary by type and size of the
organization as well as the services provided in the emergency department.
Education and training includes information on the definition of imminent
death, the use of clinical referral triggers, and who to contact when potential
organ and tissue donation opportunities arise. Team members, (e.g., nurses,
physicians, or respiratory therapists) are educated on when and how to
make referrals to physicians qualified to determine neurological death or how
to link with donation services such as an OPO.
10.6 The team receives training and education on how to support and provide
information to families of potential organ and tissue donors.
Platinum
Effectiveness
Guidelines
Education and training includes information on respecting the family's culture

and beliefs when discussing organ and tissue donation, who is appropriate
and qualified to approach the families of potential donors, approaches to
take when discussing organ and tissue donation (e.g., the decoupling
approach), and others to involve in discussions with the family (e.g., social
worker, spiritual advisory, or a representative from an OPO).
10.7 The team notifies the OPO or tissue centre in a timely manner when death is
imminent or established for potential donors.
Platinum
Efficiency
Guidelines
Rapid notification of potential donors to the OPO increases the likelihood of

organ and tissue donation.
In many jurisdictions, legislation specifies procedures to be followed when

death is imminent. In those provinces, team members are required by law to
notify their OPO when a client has died or a physician has made an NDD.
10.8 The team records all aspects of the donation process, including the family's
decision about organ and tissue donation, in the client record.
Gold
Effectiveness
Guidelines
The client record shows that the client was identified as a potential donor,
the family was approached for donation, and the OPO was contacted, as
well as the decision about organ and tissue donation.
11.0 The team provides safe and effective care to clients in the emergency
department.
11.1 The team works to ensure that client privacy is respected during registration.
Client-centred Platinum
Services
Guidelines
Often clients disclose personal information during registration such as the

reason they are presenting in the emergency department. It is important that
the team respects client privacy during this process.
11.2 The team follows a process for clients who sign out, or discharge, against
medical advice.
Continuity of Platinum
Services
Guidelines
The team makes every reasonable attempt to convince the client of the need
for further assessment and care, including the potential consequences of the
decision to refuse further care. In the end, the team respects the client's right
to leave the hospital against the medical advice of the treating physician so
long as he/she is competent and does not present a danger to him/herself or
to others.
The process includes an evaluation of the clients' competency; in order to

sign out against medical advice the client must be capable of giving informed
consent or be represented by a legally authorized substitute decision maker.
The clients' medical history and assessment is documented as much as
possible, including when the client refuses any part of the assessment. The
team determines the appropriate care for the client and describes this to the
client in easily understood terms. The team informs the client of the need for
further assessment.
11.3 An appropriate team member explains to the client, and family if available,
the anticipated sequence of events for service delivery, locations where
services will be provided, and by whom. Gold
Client-centred
Services
Guidelines
The team works to ensure that the client and family understand the
information provided. The team considers level of understanding, literacy,
language, disability, and culture when providing information to clients.
Clients and families have an opportunity to ask questions regarding service

delivery.
11.4 The team follows the organization's policy to obtain the client's informed
consent to treatment and/or investigation.
Gold
Effectiveness
Guidelines
Informed consent consists of reviewing service information and the consent

form with the client; informing the client about the available options and
providing time to reflect and ask questions before asking for consent;
respecting the client's rights, culture, and values as they relate to informed
consent, including the right to refuse consent at any time; and recording the
client's decision in the client record.
Implied consent occurs when providing services where written consent is not
needed, such as when clients willingly present themselves to the emergency
department registration desk, are brought for service through EMS, or
present with life-threatening or emergent condition(s) and require immediate
resuscitation.
When dealing with minors such as children and youth, the team's consent
process includes involving the minors as much as possible in decision-
making about their service, intervention, or treatment, and valuing their
questions and input.
The team complies with federal and provincial/territorial legislation.
11.5 When clients are incapable of giving informed consent, the team refers to the
client's advance directives if available and/or obtains consent using a
substitute decision maker. Platinum
Effectiveness
Guidelines
Clients who are incapable of providing consent may have advance directives
to guide certain or all decisions. The team records advance directives in the
client record and shares this information with service providers in and
outside of the organization, as appropriate.
The team may also consult with a substitute decision maker when clients are
unable to make their own decisions. In these cases, the team provides the
substitute decision maker with information on the roles and responsibilities
involved in being a substitute decision maker, and discusses questions,
concerns, and options. A substitute decision maker may be specified in
legislation or may be an advocate, family member, legal guardian, or
caregiver.
If consent is given by a substitute decision maker, the name of the substitute

decision maker, the relationship to the client, and the decision made is
recorded in the client record.
The team complies with federal and provincial/territorial legislation.
11.6 REQUIRED ORGANIZATIONAL PRACTICE: The team implements a client

verification protocol for all services and procedures.
Gold
Safety
Guidelines
Wristbands are almost universally used in acute care settings for identifying
patients; see the National Patient Safety Agency website for more
information: http://www.npsa.nhs.uk/nrls/alerts-and-directives/notices/wristba
nds/. The client's first and last name, their date of birth and their local
hospital number are the identifiers most commonly used.

The organization has a documented method of client
11.6.1 identification (e.g. wrist bands, photo identification) that is
standardized across the organization.
The team uses at least two methods (e.g. name and date of
birth) to identify a client before providing any service or
11.6.2
procedure. The client's room number cannot be used to identify
the client.
11.7 The team uses evidence-based care protocols when providing emergency
department services to clients.
Diamond
Safety
Guidelines
Use of evidence-based care protocols assists staff and service providers to

effectively identify, address, and manage health care needs of clients, and
minimizes treatment variations.
Care protocols for emergency departments may include anaphylaxis,

asthma, gastroenteritis and dehydration, pain, suspected neonatal sepsis,
septic shock, seizures and status epilepticus, procedural sedation, and
radiology.
Since evidence-based care protocols are normally developed in an urban

setting, organizations in rural communities need to evaluate the applicability
of these protocols to ensure they meet the needs of their emergency
department.
11.8 The team adheres to assigned roles and responsibilities during the
resuscitation of clients.
Platinum
Effectiveness
Guidelines
The team knows its roles and responsibilities, including leadership roles,
enabling it to work and communicate effectively as a team during
resuscitation.
11.9 The team monitors clients who have received sedatives or narcotics.
Gold
Safety
Guidelines
The team follows a protocol to monitor and document the status of clients
who have received sedatives or narcotics while in the emergency
department.
11.10 The team has access to information on pediatric medication dosages.
Gold
Safety
Guidelines
Validated and approved dosing references for pediatric medications are
readily available to the team to reduce prescribing errors related to
inaccurate weight-based dose adjustments.
11.11 The team administers medications to pediatric clients using weight-based

pediatric dosages and appropriately sized equipment.
Gold
Safety
11.12 The team has a policy and process to manage medico-legal issues in the
Emergency Department.
Diamond
Safety
Guidelines
The team provides training to staff in the Emergency Department on the

identification and management of medico-legal issues such as police cases
(e.g., indications of domestic violence and abuse, indications of violent
crimes, gunshot wounds); consent to treatment; involuntary clients; client
refusals; withdrawal of life support; clients who are dead on arrival; and
safety, security and confidentiality of client identification.
12.0 The team prepares clients and families for transition to another service
team or setting, service provider, or end of service.
12.1 The team applies clinical guidelines to determine whether a client is fit for
transfer of care.
Gold
Safety
Guidelines
Transfer of care may be within the organization or outside of the

organization.
Guidelines may include different protocols for populations or conditions (e.g.,

post-sedation, procedural sedation, frail-elderly populations) as well as a
review of criteria such as control of pain, nausea, or vomiting, and
appropriateness and safety of discharge destination. Guidelines include
information on transfer of clients who are not stable and requirements during
transfer (e.g., monitoring during transfer, equipment necessary for transfer,
what team members must be present during transfer, and pre-transfer
assessments).
12.2 The team works with health services both within and outside of the
organization to coordinate the client's services.
Services
Guidelines
Health services inside the organization may include other services including
inpatient services and ambulatory services. Services outside the
organization include community health services, primary care, other primary
health care services or community-based services, home care, social
services, specialized treatment centres, and long-term care.
12.3 The team works with clients and families to ensure they know what to expect
during transition or end of service.
Services
Guidelines
Continuity of care is enhanced when clients have comprehensive information

about transitions and end of service. The team provides the client with clear
and easy-to-understand information about the next steps in care, including
instructions or follow up. Information provided to the client and family
includes the client's service plan, goals, and preferences; a summary of the
care provided; an updated list of outstanding issues, clinical or otherwise;
what to expect during transition or at end of service; and contact information
for the team and details on when clients should contact the team, (e.g., if
clients notice any warning signs or symptoms of adverse reactions).
12.4 The team transfers the information obtained from EMS, triage, assessment,
and admissions to service providers in the next setting.
Platinum
Effectiveness
12.5 The team reconciles medications with the client at referral or transfer and
communicates information about the client's medications to the next provider
of service at referral or transfer to another setting, service, service provider, Platinum
Safety or level of care within or outside the organization.
Guidelines
Medication reconciliation is a way to collect and communicate accurate

information about client medication, including over-the-counter medications,
vitamins, and supplements. Poor communication about medication at
transition points can cause errors and adverse events.
Medication reconciliation is a shared responsibility which must involve the
client or family. Liaison with the primary care provider and community
pharmacist may be required.
12.6 REQUIRED ORGANIZATIONAL PRACTICE: The team transfers information

effectively among providers at transition points.
Services
Guidelines
Transition points are defined as handovers in the care of a client, including

between staff, change of shift, between patient care units, and to the patient
and next care provider upon discharge.
Important information transferred during a period of care should include:
client's status, medications, treatment plans, advance directives, and
significant status changes.
Important information transferred upon discharge should include the client's
discharge diagnoses, treatment plans, medications, and test results.
Many organizations are adopting the SBAR (situation, background,
assessment) technique as a standardized approach to transfer of client
information. SBAR is a structured communication technique designed to
convey a great deal of information in a succinct and brief manner. Situation
refers to a concise statement of the problem; Background requires pertinent
and brief information related to the situation; Assessment involves providing
analysis and considerations of options; and Finalize is indicating your
request or recommend action.
Mechanisms to implement a standardized transfer of client information can
include forms and checklists. An example form for transferring client
information using the SBAR technique is available at the Institute for
Healthcare Improvement (IHI) website at: http://www.ihi.org/IHI/Topics/Patien
tSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalB
riefingModel.htm.

The organization has a documented protocol to transfer client
information (e.g. using a read-back technique, SBAR, or
12.6.1
electronic medical records) during transition points that is
standardized across the organization.
12.6.2 The team uses mechanisms (e.g. transfer forms, checklists) for
timely transfer of client information at transition points that result
in proper information transfer.
12.7 The team documents a complete record of the transfer in the client health
record, including a summary of services provided.
Gold
Effectiveness
Guidelines
The summary includes the reason for the assessment; test results and
significant findings; the client's diagnosis, a list of all services and any
procedures performed; a list of all medications and other treatments; a
summary of the service plan and whether or not the service goals were
achieved; details regarding transfer, including the client's condition; and end
of service instructions, medications, and follow-up.
MAINTAINING ACCESSIBLE AND EFFICIENT CLINICAL INFORMATION SYSTEMS

13.0 The team keeps client records accurate, up-to-date, and secure.
13.1 The team maintains an accurate and up-to-date record for each client.
Gold
Effectiveness
13.2 The team meets applicable legislation for protecting the privacy and
confidentiality of client information.
Client-centred Gold
Services
Guidelines
Applicable legislation may be national or provincial/territorial.
13.3 The team uses a unique client identifier such as a given number, to link the
record to the client.
Gold
Effectiveness
13.4 The team has a standardized process to maintain all diagnostic tests,
services, and medications in the client health record, as well as a list of the
team members involved in the client's care. Gold
Effectiveness
Guidelines
Often referred to as charting, the team's process ensures that the services
provided to clients are consistently and precisely recorded.
13.5 The team stores client records in a way that protects the privacy and
confidentiality of client information.
Client-centred Gold
Services
Guidelines
Methods for protecting the privacy and confidentiality of client information

depend on whether the record is electronic or paper-based. For example, for
paper-based files, the team has a secure storage area; for electronic files,
the team may use a password-protected system to limit access to client
information. Non-lockable files (or a non-secure computer) should only be
available in working areas.
If applicable, the team should meet established regulations or legal
requirements for protecting the privacy and confidentiality of client
information.
13.6 Appropriate team members have timely access to the client record.
Gold
Accessibility
Guidelines
The organization has policies outlining who may access client information,
and how and when they may do so.
Team members make it a priority to read and understand client records.
Failing to be aware of information contained in the client record can lead to
breakdowns in the continuity of care and services, and create unnecessary
gaps or duplication.
13.7 The team shares client information and coordinates its flow among service
providers, other teams, and other organizations, as required.
Services
Guidelines
While maintaining an awareness of the client's right to privacy, the team

shares information as required to facilitate transfers, and to reduce
duplication in obtaining client information.
14.0 The team has access to information technology to deliver emergency

14.1 The team has timely access to information technology that impacts client
care.
Gold
Effectiveness
Guidelines
Examples of technology include electronic health records, client tracking

systems, wait list management systems, client self-assessment tools, and
access to national and provincial/territorial databases where available.
Innovative information technology is used to support the work of the service
area.
14.2 The team uses information technology to share information with the
interdisciplinary team.
Continuity of Diamond
Services
Guidelines
To enhance communication, the team uses appropriate information

technology to communicate with other services which may include primary
health care providers, EMS, pharmacy, diagnostic imaging services, and
alternative levels of care.
14.3 The team identifies its needs for new technology and information systems.
Platinum
Effectiveness
Guidelines
Technology and information systems used in the emergency department

need to be up-to-date and effectively support service delivery and team
functioning. The team works together to identify when needs arise and
advocate for new technology and information systems.
14.4 Team members receive education and training on information systems and
other technology.
Platinum
Worklife
Guidelines
Required skills may include knowledge of computer applications, word-
processing software, and how to use the Internet.
HAVING A POSITIVE IMPACT ON OUTCOMES

15.0 The team uses evidence-based guidelines and best practice
information to improve the quality of its services.
15.1 The team accesses evidence-based guidelines for emergency department

services.
Gold
Effectiveness
Guidelines
The team refers to guidelines for delivering emergency department services.

Guidelines may be established internally by a committee, a council, or an
individual who develops tools and makes recommendations to the team
based on evidence-based information. Guidelines from other organizations
or associations may also be adopted by the team.
15.2 The organization has a process to select evidence-based guidelines for

emergency department services.
Platinum
Effectiveness
Guidelines
Evidence-based guidelines may be established internally by a committee, a

council, or an individual who develops tools and makes recommendations to
the team.
Guidelines from other organizations or associations may be adopted by the

team. The process for selecting guidelines is standardized and formalized. It
may include using content experts, a consensus panel, or the Appraisal of
Guidelines Research and Evaluation (AGREE) instrument, which allows
organizations to evaluate the methodological development of clinical practice
guidelines from six perspectives: scope and purpose, stakeholder
involvement, rigour of development, clarity and presentation, applicability,
and editorial independence.
Comprehensive documents that synthesize evidence from several guidelines

are also available. For example, the Cochrane Collaboration conducts
systematic reviews of the available evidence; this can help service providers
and organizations with their review process. Where synthesized information
is not available, the organization has a process to deal with and decide
among conflicting guidelines or multiple recommendations.
Evidence-based guidelines for emergency departments include the

Canadian Association of Emergency Physician policies, position statements,
or clinical guidelines, all of which are designed to enhance service delivery in
emergency departments.
15.3 The team reviews its guidelines to make sure they are up-to-date and reflect
current research and best practice information.
Diamond
Effectiveness
Guidelines
The team's review process includes ways to access the most up-to-date
research and information, (e.g., through literature reviews, content experts,
national organizations or associations, or the Cochrane Collaboration).
Research information may include intervention research, program
evaluations, and clinical trials.
15.4 The team's guideline review process includes seeking input from team
members about the applicability of the guidelines and their ease of use.
Platinum
Effectiveness
15.5 The team's research activities for emergency department services meet
applicable research and ethics protocols and standards.
Gold
Effectiveness
Guidelines
The team may participate in research initiatives to improve the quality of care
to emergency department clients (e.g., clinical trials, assessments of new
interventions, or changes to existing ones).
Research and ethics protocols and standards include those for client
consent to participate in research activities.
15.6 The team shares benchmark and best practice information with its partners
and other organizations.
Diamond
Population Focus
16.0 The team promotes safety in the service environment.
16.1 The team takes a proactive approach to team safety in the emergency
department.
Platinum
Safety
Guidelines
Due to the nature of emergency care, there may be additional safety risks to
the team. The team works with the organization to prevent risk where
possible. This may include training for team members, additional security
during peak hours, or establishing protocols for team members to follow.
16.2 The team identifies, manages, and isolates clients with known or suspected
infectious diseases.
Gold
Safety
16.3 Each team member is regularly screened and receives immunizations, as

applicable, for common infectious diseases.
Gold
Safety
Guidelines
The most common infectious diseases include tuberculosis, measles,

rubella, polio, influenza, tetanus, diphtheria, and pneumococcus. The team
may also decide to screen and immunize team members for other diseases,
depending on the types of clients seen and services provided by the team.
16.4 REQUIRED ORGANIZATIONAL PRACTICE: The team implements and

evaluates a falls prevention strategy to minimize client injury from falls.
Platinum
Safety
Guidelines
Falls may lead to client injury, increased health care costs, and possibly
claims of clinical negligence.
Falls prevention programs may include but are not limited to staff training,
risk assessments, balance and strength training, vision care, medication
reviews, physical environment reviews, behavioural assessments, and bed
exit alarms. Possible measures to evaluate a falls prevention strategy may
include tracking the percentage of clients receiving a risk assessment, falls
rates, causes of injury, and balancing measures such as restraint use.
Conducting post-fall debriefings may also assist to
identify safety gaps, and to prevent the recurrence of falls.
The World Health Organization has identified falls prevention as an important

global health issue. Reducing falls and fall injuries can increase quality of life
for clients and reduce costs associated with serious injury from falls.

16.4.1 The team has implemented a falls prevention strategy.
16.4.2 The strategy identifies the populations at risk for falls.
The strategy addresses the specific needs of the populations at

16.4.3
risk for falls.
The team establishes measures to evaluate the falls prevention

16.4.4
strategy on an ongoing basis.
The team uses the evaluation information to make

16.4.5
improvements to its falls prevention strategy.
16.5 Team members participate in regular safety briefings to share information

about potential safety problems, reduce the risk of error, and improve the
quality of service. Platinum
Safety
Guidelines
Regular opportunities to share information about potential problems and

actual incidents can reduce risk and the likelihood of an incident recurring.
16.6 REQUIRED ORGANIZATIONAL PRACTICE: The team informs clients and

families in writing and verbally about their role in promoting safety.
Gold
Safety
Guidelines
Clients and families play an important role in preventing adverse events.

Their questions and comments are often a good source of information about
potential risks, errors, or safety issues. Clients and families are able to fulfill
this role when they are included and actively involved in the process of care.
Many organizations have developed materials that relate to client safety-

related issues and provide guidance and direction for questions and topics to
address during care. An example of client safety educational material
includes the National Patient Safety Foundation's “Ask Me 3”.

The team develops written and verbal information for clients
16.6.1
and families about their role in promoting safety.
The team provides written and verbal information to clients and

16.6.2
families about their role in promoting safety.
16.7 The team identifies, reports, records, and monitors in a timely way sentinel
and adverse events and near misses.
Gold
Safety
Guidelines
Investigating sentinel and adverse events and near misses includes taking
action to prevent the same situation from recurring, monitoring incidents, and
using lessons learned to make improvements.
Team members delivering emergency department services are responsible
for implementing the organization's process. In addition, information about
sentinel and adverse events and near misses is tracked for emergency
department services specifically and reported in a manner that is consistent
with others across the organization so that the information may be
summarized at the organization level.
16.8 The team follows the organization's policy and process to disclose adverse
events to clients and families.
Platinum
Safety
Guidelines
This criterion is linked to the Required Organizational Practice in the

Leadership Standards that requires organizations to have a formal process
to disclose adverse events to clients and families.
17.0 The team collects and uses indicator data to guide its quality
improvement initiatives.
17.1 The team collects information and feedback from clients, families, staff,
service providers, organization leaders, and other organizations about the
quality of its services to guide its quality improvement initiatives.
Client-centred Gold
Services
Guidelines
The team gathers information and feedback in a consistent manner from its
key stakeholders about the quality of its services. Feedback, in the form of
client and family satisfaction or experience data, complaints, indicators,
outcomes, scorecards, incident analysis information and financial reports,
may be gathered by a variety of methods, including surveys, focus groups,
interviews, meetings, or records of complaints.
17.2 The team uses the information and feedback it has gathered to identify
opportunities for quality improvement initiatives.
Platinum
Effectiveness
Guidelines
The team uses feedback as well as other forms of information, and

observation and experience, to identify and prioritize areas for quality
improvement initiatives. This is done using a standardized process based on
criteria such as client-reported outcomes, risk, volume, or cost.
17.3 The team identifies measurable objectives for its quality improvement
initiatives and specifies the timeframe in which they will be reached.
Gold
Effectiveness
Guidelines
Quality improvement objectives define what the team is trying to achieve,

and by when. Appropriate quality improvement objectives have targets that
exceed current performance. Quality improvement objectives are typically
short term and are aligned with longer-term strategic priorities or patient
safety areas. The timeframe will vary based on the nature of the area for
improvement.
The SMART acronym is a useful tool for setting meaningful objectives, in

that they should be Specific, Measurable, Achievable, Realistic, and Time-
bound. The United States Centers for Disease Control and Prevention offers
a guide to writing SMART objectives.
17.4 The team identifies the indicator(s) that will be used to monitor progress for
each quality improvement objective.
Gold
Effectiveness
Guidelines
The team uses indicators to monitor whether the activities resulted in change
and if the change is an improvement. Primarily, indicators are selected based
on their relevance and ability to accurately monitor progress. When there are
multiple potential indicators, the team uses criteria to select indicators, such
as scientific validity and feasibility. If the team has difficulty selecting
indicators, it may mean the quality improvement objective needs further
clarification.
17.5 The team designs and tests quality improvement activities to meet its
objectives.
Platinum
Effectiveness
Guidelines
Quality improvement activities are the actions used to initiate improvements,

and are part of the larger quality improvement plan. Activities are first
designed and tested on a small scale to determine their effect prior to
implementing them more broadly.
The Getting Started Kit for Improvement Frameworks is a resource created

by the Canadian Patient Safety Institute and is based on the Model for
Improvement. The Institute for Healthcare Improvement offers a framework
to guide quality improvement activities using Plan, Do, Study, Act cycles.
17.6 The team collects new or uses existing data to establish a baseline for each
indicator.
Platinum
Effectiveness
Guidelines
Establishing a baseline reference point makes it possible to monitor progress

towards meeting quality improvement objectives by comparing pre- and post-
activity data and noting changes. Establishing a baseline may require one or
many data points, and occurs over a defined period of time. Once the
baseline is established, the team may need to reevaluate their quality
improvement objectives to ensure they remain feasible and relevant.
17.7 The team follows a process to regularly collect indicator data to track its
progress.
Platinum
Effectiveness
Guidelines
The team determines how the data will be collected and how often it will be
collected. Regularly collecting data allows the team to track its progress over
time and understand the normal variation of values.
17.8 The team measures ambulance offload response times, and uses it to set
target times for clients brought to the emergency department by EMS.
Platinum
Effectiveness
Guidelines
Data for ambulance offload times is tracked to allow the team to identify
patterns over time.
17.9 The team tracks and benchmarks data on wait times for services, the length
of stay in the emergency department, and the number of clients who leave
without being seen. Diamond
Accessibility
Guidelines
The data is assessed against the CTAS levels. Length of stay data are
collected for all clients (admitted and not admitted).
17.10 The team regularly analyzes and evaluates its indicator data. to determine
the effectiveness of its quality improvement activities.
Platinum
Effectiveness
Guidelines
The team compares the intended and actual effects of its quality
improvement activities, and, if the objective has not been achieved, adjusts
its actions accordingly to meet the objective.
Analyzing data identifies trends and may reveal service areas that may need
to be considered for quality improvement initiatives. Indicator data collected
over time can be displayed in a run chart or control chart, both of which are
valid means of data analysis. Safer Healthcare Now! offers Patient Safety
Metrics, a web-based tool where organizations can submit data on various
interventions, analyze results over time, and generate reports.
If it is not within the team's capacity to analyze the data, it seeks qualified
internal or external assistance.
17.11 The team implements effective quality improvement activities broadly.
Platinum
Effectiveness
Guidelines
The team broadly implements the quality improvement activities that were
shown to be effective in the testing phase. The way in which the team
implements activities broadly will vary based on the scope and scale of the
team's services and considers the timeframe, e.g., an effective activity is
implemented in more than one area of care and for a longer period of time.
17.12 The team shares information about its quality improvement activities, results,
and learnings with clients, families, staff, service providers, organization
leaders, and other organizations, as appropriate. Diamond
Population Focus
Guidelines
The team tailors the information to the audience and considers the
messaging and language level that is appropriate for each audience.
Sharing the results of evaluations and improvements helps staff, service

providers, and stakeholders become familiar with the philosophy and
benefits of quality improvement and engages the organization's leaders in
the process. It also helps the organization to spread successful quality
improvement activities within and outside the organization and demonstrate
its commitment to ongoing quality improvement. Among other benefits,
sharing indicator data externally allows for comparison with organizations
offering similar services.
17.13 The team regularly reviews and evaluates its quality improvement initiatives
for feasibility, relevance and usefulness.
Diamond
Effectiveness
Guidelines
The team regularly reviews and evaluates its quality improvement initiatives,
including its activities, objectives, and indicators. The team uses the
information to plan its future quality improvement initiatives including how
and when to sustain or spread existing initiatives within the organization. The
team considers outcomes of the quality improvement initiatives as they align
with the organization's overall quality improvement plan, goals and
objectives, mission and values, and strategic plan. The team evaluates
whether objectives were met within their timeframes and whether the
timeframes remain relevant.
Based on the review of the initiatives, objectives and indicators may be

added, amended, or removed as appropriate. The rationale for amending or
removing them is documented.
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This publication is provided by Accreditation Canada. This publication, and all content contained herein, is
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You are entitled to use this publication internally within your organization for information purposes only. You
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Emergency Department Accreditation Canada International

v3
Legend:
Population Focus Working with communities to anticipate and meet needs
Accessibility Providing timely and equitable services
Safety Keeping people safe
Worklife Supporting wellness in the work environment
Client-centred Services Putting clients and families first
Continuity of Services Experiencing coordinated and seamless services
Effectiveness Doing the right thing to achieve the best possible results
Efficiency Making the best use of resources
Criterion Types:
Required Organizational Practices Required Organizational Practices (ROPs) are essential practices that an
organization must have in place to enhance client safety and minimize risk.
Performance Measures Performance measures are evidence-based instruments and indicators that are
used to measure and evaluate the degree to which an organization has
achieved its goals, objectives, and program activities.
Priority:
High Priority High priority criteria are criteria related to safety, ethics, risk management, and
quality improvement. They are identified in the standards.
Levels:
Gold addresses basic structures and processes linked to the foundational elements of
safety and quality improvement.
Platinum builds on the elements of quality and safety, and emphasizes key elements of
client-centred care, creating consistency in the delivery of services through
standardized processes, and involving clients and staff in decision-making.
Diamond focuses on the achievement of quality by monitoring outcomes, using evidence

and best practice to improve services, and benchmarking with peer
organizations to drive system-level improvements.

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The Structure of the Standards

INVESTING IN EMERGENCY DEPARTMENT SERVICES

1.1 The organization has a current license to offer emergency department

1.2 The organization's license clearly states which emergency department

1.3 The organization's policies and procedures for delivering emergency

If it is not within a team's mandate to collect information, it knows how to

Emergency departments work with many different organizations, partners,

Expectations regarding the team's scope of services may be outlined in

1.8 The team works together to develop goals and objectives.

1.11 The team collaborates with its partners to develop resource-sharing

Partners include those within and external to the organization.

Standard sized equipment and supplies are normally inappropriate for

The Canadian Association of Emergency Physicians also provides a list of

3.2 The team works in collaboration with organizational leaders to take a

A proactive approach to managing overcrowding in the emergency

Other services or teams include medicine services, critical care, surgical

Barriers to access include: overcrowding as a result of breakdowns in client

Partners include other emergency health partners and other referral or

Partners outside of emergency health include referring areas of the

Efficient transportation to the appropriate organization ensures that clients

3.8 The team follows standardized processes and procedures to coordinate

This may include transfer to a higher level of care or specialized services

Other health care services and programs may include community-based

Protocols are developed in partnership with other teams and community

In addition to limiting access to timely and appropriate care, overcrowding is

3.13 The team follows organizational protocols to manage overcrowding and

Often protocols are established by the region where the organization is

HAVING THE RIGHT PEOPLE

4.1 The organization identifies a multidisciplinary team to deliver emergency

4.2 The team leaders are certified medical doctors.

4.3 The multidisciplinary team includes consultants and referring medical

Position profiles include a position summary, specify qualifications and

Role clarity is essential in promoting client and staff safety, as well as a

4.5 The multidisciplinary team communicates regularly to coordinate services,

Miscommunication or a lack of communication among interdisciplinary team

Communication mechanisms can include meetings, teleconferences, or

The team's process to evaluate its functioning includes a review of its

5.0 Team members are educated, trained, qualified, and competent.

For example, physicians should be licensed by the applicable regulatory

The qualifications of team members who are not regulated by professional

The orientation program covers the organization's mission, vision, and

Orientation includes the specific nature of the emergency department; the

Orientation also includes how risks (e.g., potentially violent or aggressive

5.6 REQUIRED ORGANIZATIONAL PRACTICE: The organization provides

Organizations are also encouraged to standardize infusion pumps to the

Test(s) for Compliance

Training may include triage policies, process, and documentation; decision

An interdisciplinary approach to education and training may be used to

Violence includes abuse, aggression, threats, and assaults. Workplace

The training and education addresses the following core competencies:

Reporting includes perceived, potential, or actual incidents of violence.

Cultural competency is a set of skills that allows team members to increase

Training addresses the unique needs of pediatric clients including

Team leaders use the organization's established process to evaluate each

When evaluating performance, team leaders review the individual's ability to

A performance evaluation is usually done before the probationary program is

The criteria are based on accepted standards of practice, legal

Common risks may include aggressive and violent behaviour or security

Recognition activities may be individual, such as service awards based on

DELIVERING QUALITY EMERGENCY DEPARTMENT SERVICES

The emergency department is identified through appropriate signage. This