Comfort. Care. Compassion.

Accreditation Updates

This page lists monthly updates around Normanna’s internal changes and processes related to the Accreditation Canada process.

July 2018

Overview of status for the Accreditation team as of July 6th:

  1. Round table.
    • HR Plan – Leadership have discussed an HR plan – While surveyors do not usually ask for an HR plan, it will be beneficial to talk about the changes in the extra funding for front line staff.
    • Involvement with families at Normanna has been a struggle, but with the monthly newsletter, this should help.
    • Preventative Maintenance – POCT (Point of Care Testing) – The new terminology in the standards.
    • Communication, risk management, quality improvement, strategic and operational plans have been implemented and will be presented to the Board for approval on 16th July.
    • Resident Safety Plan to be approved by the Leadership Team and Normanna Board of Directors.
    • A conference call with surveyors will take place in September/October with Accreditation specialist and surveyors.  A mock survey will be conducted in October.
  2. Review of revised Critical Path and assigned goals and timelines
    • In progress
  3. Progress Report Action Plans – Leadership/LTC/Employee Satisfaction Survey results
    • Education Plan – The education calendar is being followed.  Leadership to get together to ensure the education binder has all relevant documents.
    • Leadership Plan – Red and yellow themes have been reviewed.  Timelines have been outlined for leadership to follow up.
    • Long Term Care Plan – Teams meet and prioritize the education.
    • Employee Satisfaction Survey – In total 49 surveys were completed and results have been posted on the resident board.
  4. Operation Plan – Review and assignments
    • Will be reviewed once the Board has approved
  5. Quality Improvement Committee and QI Project update – Restraints/Med Reconciliation/Workload
    • Reporting Indicators – The indicators will be presented to the entire Board at the next meeting, especially for benefit of 2 new Board Members.
    • QI Projects (Medication Management and Least Restraints) have been completed and education for staff has been scheduled.
    • UTI has been added as an FHA initiative – data is being collected on a monthly basis and being sent to FHA.
  6. Clinical Audit Committee
    • Audits have been streamlined and a now compliance audit tool is used and the Board is informed of the results.
  7. Ethics Committee Meetings/Education
    • Monthly meetings are scheduled with the Ethics Committee.
  8. Health & Safety Policies
    • Policies are completed.  Education on emergency preparedness will be done in September.
  9. Preventative Maintenance
    • Data is currently being entered manually.  The same data can be pulled on Maintenance Care electronically to save time.  Maintenance Care training to be arranged for Leadership in September.
  10. POCT Policy
    • Forwarded to Leadership for review
  11. Support Services Audit
    • Quarterly audit reports are sent to Leadership which are to be integrated into the QI report.
  12. Emergency Preparedness – Manual and Testing
    • Will be done in September/October
  13. Staff Education Calendar updates
    • Calendar is being updated as policies are being changed.
  14. Priority Processes
    • A QI committee has been implemented.  Staff suggesting a soft rotation. Member of Leadership and one staff from each pod.

April 2018

High level summary of Accreditation leadership meeting on April 30th:

Continue to work on communicating expectations around the Accreditation process with the different departments in Normanna.  Focusing on what to expect when the surveyors actually come to to do the survey as well as look at areas such as communication, emergency preparedness, care, human capital, infection control, quality improvement.  The operational plan is to be reviewed in mid May.

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Our Mission

Normanna provides quality residential healthcare services that reflect the values of trust, respect, caring and diversity.


Contact Information ..

7725 4th Street
Burnaby, BC
V3N 5B6
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Office Hours:
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12noon – 1 pm
Monday - Friday | All Statuary Holidays
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Normanna is one of a few care facilities in Canada to have earned Accreditation with Exemplary Standing from Accreditation Canada for 2014 - 2018. Accreditation Canada certifies that Normanna and its contractors meet the national standards of quality for health services set by the Council.