Bermuda Hospitals Board Achieves Highest Level of Accreditation

Bermuda Hospitals Board today announces that it has achieved unconditional Accreditation. In July 2008, BHB made public for the first time the preliminary report from Accreditation Canada, with a forecast result of Accreditation with Condition (Report) – the second highest level of accreditation. After providing evidence that required outstanding practices and standards had been met by 24 December 2008, this result was upgraded to the highest level of Accreditation, a result only 20% of Canadian hospitals achieve.

The final report records that all 25 Safety Areas for Required Organisational Practices (which BHB calls Patient Safety Goals) are now being met at BHB, which is a requirement for this level of accreditation. Additionally, BHB’s compliance rate was higher than Canada’s national compliance rate in all eight of the Quality Dimensions and in all but two of the 16 High Priority Criteria measured by Accreditation Canada.
In the interests of transparency the final report is being made public and is on the BHB website at This final report has never been made public by the BHB in any of its previous accreditation surveys and reflects the current Board’s commitment to being open and accountable to the Bermuda public.

This result is an improvement on 2005 when BHB was awarded Accreditation with Focused Visit, even though the new process in 2008 was more robust and, for the first time, BHB was working to Canadian standards, which are more stringent that those used by Accreditation Canada’s international hospitals.

Wendy Nicklin, CEO of Accreditation Canada, comments: “We are very impressed by the progress Bermuda Hospitals Board has made since their last accreditation. People in Bermuda should be extremely proud of what their hospitals have achieved and feel reassured that BHB has chosen to be measured against standards of excellence. This is an important step in Bermuda Hospitals Board’s ongoing journey of quality improvement.”

BHB CEO, Mr Hill, comments: “We are proud that so much progress has been made, especially as this was the first time we had been tested by a new, much more robust process and the first time that we had measured ourselves against Canadian hospital standards. We chose to move to the Canadian hospital standards as they are more stringent. This reflects the high expectation of our Board and also the community as a whole. We also recognise that this is a continuous process and we need to ensure achievements are maintained and new standards are introduced.”

Acting Chief of Nursing, Quality & Risk Management, Judy Richardson, comments: “Accreditation is about continuous improvement. This was a tough, thorough process and we know there will always be room to improve as standards and goals are constantly changing in healthcare and we already have new Patient Safety Goals that were introduced by Accreditation Canada for 2009. However, this achievement shows that we have established standards of care that are comparable to hospitals in Canada. We are continuing to work hard in many areas and not only respond to Accreditation requirements, but also listen to our patients about their experiences with us so that we can aim to truly excel in both in the quality of our service and standard of our care.”

Chairman, Mr Herman Tucker, comments: “I would like to congratulate the staff at Bermuda Hospitals Board for achieving accreditation, and successfully responding to a more robust process than before and against tougher standards. As a Board we believe in measuring ourselves against the highest standards. We believe that by working together and continuously improving we can become a first class operation that people in Bermuda trust with their care. What this Accreditation tells us is that we provide safe standards of care and that the hard work that has taken place so far is paying off. We have more improvements to make and we remain committed to strive for the best.”

Update on progress since December 2008:

Although BHB has achieved unconditional accreditation, Accreditation Canada expects process improvements to be a continuous activity. Based on collated information on 24 December, Accreditation Canada noted four criteria still needed to be met. These final five criteria did not impact the final result as they represent less than 10% of the entire list of criteria (there are 1,555 Accreditation Canada criteria applicable to BHB) and all Required Organisational Practices were met. As progress has continued since 24 December at BHB, however, below is an update on where BHB is in meeting these standards.


The organisation uses a computerized prescriber order entry (CPOE) system with the capacity to guide the use of accepted drugs and established protocols, and alert attention to unsafe orders during input – 48% of Canadian hospitals meet this criteria


A project has been initiated to introduce this system as part of Bermuda Hospitals Boards IT strategy. There are checks in place at BHB around drug usage, but the CPOE is the recognised standard BHB is working towards.


The pharmacy uses a biohazard hood for antineoplastic products – 95% of Canadian hospitals meet this criteria


The hood is currently being installed and is expected to be operational this month (March).


Following transition or end of service, the team contacts clients, families, and referring providers to evaluate the effectiveness of the transition, and uses this information to improve its transition and end of service planning, as appropriate – 42% of Canadian hospitals meet this criteria

The team monitors clients’ perspectives on Ambulatory Care services- 53% of Canadian hospitals meet this critieria


Both these critera were met in January 2009 with the introduction of a new patient telephone survey that asks about the effectiveness of the transition process and asks clients about their perspective of KEMH’s ambulatory services.


Following transition or end of service, the team contacts clients, families, and referring providers to evaluate the effectiveness of the transition, and uses this information to improve its transition and end of service planning, as appropriate – 44% of Canadian hospitals meet this criteria


A patient satisfaction survey is being devised for patient groups at the Mid-Atlantic Wellness Institute and is expected to be introduced within the next few months. The survey will include specific questions about the effectiveness of patient transition.


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