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Bethany Lodge

Quality Report


As part of Bethany Christian Living, Bethany Lodge is a 128-bed long-term care home in beautiful Unionville, Markham on a campus of care with Bethany Manor, an independent living home, Bethany Courts a life-lease development. Bethany Lodge has provided homelike Christian care since 1970. It is licensed with Ontario Health and operates under the authority of the Ministry of Long-Term Care. The Lodge offers 128 beds divided into 4 separate neighbourhoods, each fully equipped with a dining room, lounges and activity areas.

Dedicated staff provide respectful and gentle care to enhance the quality of life of our residents. Bethany provides a wide range of innovative programs and services including 24-hour nursing care two visiting Physicians and 24-hour on-call Physician coverage, Onsite Dentistry‚ Podiatry, Physiotherapy, Hearing aid and mobility aids services. The Life Enrichment team provides exciting activities‚ outings and special events. Residents have discovered new hobbies and enjoy keeping active. Bethany’s Chefs create 3 delicious meals and snacks daily. The Dietician ensures the individual dietary needs of the residents are being satisfied. The friendly team in environmental services keep a clean, well-maintained home. All linens and residents’ personal laundry is cared for.

The inviting Corner Cafe is a favourite place to catch up on the news, enjoy a coffee or have a visit. You will sometimes see clothing providers who come and set up shop several times a year, a mobile library or occasionally beautiful artwork done by the residents during the art show.

The hairdresser is conveniently located on the main floor next to the Corner Cafe. Guests enjoy complimentary parking when visiting Bethany.

The building is equipped with technologically advanced systems such as point-of-care documentation, advanced pharmacy technology, fire safety, wandering system safety and staff scheduling all lending to better care and management of quality.

With committed staff, experienced and consistent leadership and excellent partners in healthcare delivery and a number of professional partnerships Bethany Lodge is able to deliver excellent compassionate care.

Bethany Lodge’s Quality and Risk Management Program is composed of and supported by the following elements:

Bethany Lodge’s Quality Improvement and Risk Management Program will ensure that:

  • The care, programs and services provided to residents are monitored on a regular basis, and where appropriate, improvements are implemented and evaluated;
  • Planning of new services, programs and care approaches have quality improvement and risk management embedded in their structure;
  • The structural quality and integrity of the building (include systems and contents) are appropriately maintained (interior and exterior), with compliance to relevant safety standards and regulated requirements,
  • There is a focus on resident and staff health and welfare in all practices across the organization; and
  • Risk management protocols are in place and monitored for effectiveness and actions are taken to mitigate risk.

Bethany Lodge’s Quality and Risk Management Program is composed of and supported by the following elements:

  • The Kemerer Accountability Framework with the Balanced Scorecard comprised of the following five quadrants: Outstanding Resident-Focused Care and Service, Commitment to Learning & Growth, Continuous Innovation, Excellent Financial Stewardship, Dynamic Partnerships (See Bethany CQI Wheel);
  • Quality Improvement Plans have been implemented in developing of initiatives and projects. Quality Improvement Plans are presented at the CQI Committee meeting, which is ongoing and interdisciplinary.
  • Annual Strategic & Operational Plan with Corporate and Departmental goals and objectives arising from the Resident and Family Satisfaction Surveys, QI program;
  • A committee structure that supports the horizontal and vertical flow of information and decision-making at all levels of the organization including department and professional committees, and a CQI Committee with the evaluation of the Board;
  • Established policies and procedures to provide direction and guidance for the delivery of care, services and programs to residents and
  • Qualified and skilled employees with an understanding and commitment to provide a person-centered approach to care and service that meets and exceeds expectations; and
  • A Risk Management Program that ensures a safe environment for residents, families, staff, physicians, volunteers and other visitors to Bethany Lodge.

The CQI Committee will ensure that all quality improvement initiatives submitted by the departments and programs have considered the following:

  1. Reviewed the identified improvement issues and described the opportunity for improvement.
  2. Reviewed causes of issue.
  3. Generated potential solutions and selected the most promising and achievable solution(s).
  4. Identified resources required to develop and implement the improvements.
  5. Identified challenges associated with implementation of the plan.
  6. Described the identified successes with the implementation of the plan.
  7. Identified tools used in the analysis of the results of the plan and compared results with causes and opportunity for improvement comments.
  8. Recorded the process used by the team to gather and analyze data about the process improvement.
  9. Set realistic timelines for analysis of plan.
  10. Recorded lessons learned about the implementation plan and the outcomes of the continuous quality improvement plan process.
  11. Standardized continuous quality improvement by formalizing policy, procedure and practice.
  12. Recorded team actions or recommendation regarding the improvement process
  13. Recorded future plans if applicable.

The audits of the care and service operations of Bethany Lodge are an important component of the Quality and Risk Management Program. Auditing by and across departments identifies gaps and areas for improvement as well as confirming that the respective processes, structures and systems are effective and efficient. The results also serve to:

  • Plan for quality improvement initiatives and risk management strategies;
  • Assist in the evaluation of the quality of care and services;
  • Confirm that the structure and processes for care and service delivery are in order; and
  • Comply with the Fixing Long-Term Care Homes Act and Regulations and other legislation.


  1. Department and division specific operational audits will be identified and completed as per the established schedules for the various operations of Bethany Lodge.
  2. Each department head will be responsible for the completion of assigned audits according to the audit schedules.
  3. For Bethany Lodge, results will be completed and reported to the CQI Committee on a scheduled basis.
  4. Significant issues that are found through the audits will be presented to the CQI Committee for monitoring, resolution, and priority setting according to the Committees’ Terms of References.

In the first half of this year, in the development of our Quality Plan the Managers and quality committee have reviewed clinical data, IPAC audits, Resident and Family and Staff Survey results from 2021. Resident, and Family Councils feedback is also being considered. We will be monitoring and developing quality improvement plans to improve over the next 18 months. We have examined the key priority indicators from Ontario Health and continue to review and benchmark our indicators with other homes in our alliance group of homes.

We are in the process of developing the change ideas and initiatives to set achievable targets for our QIPs and to meet and exceed our goals for increased resident satisfaction. Our action plan includes working with our residents and families to improve quality of life in the home taking into consideration their feedback in the annual surveys and from communications with families.

Bethany Lodge monitors outcomes through data analysis at: leadership team and departmental meetings, resident and family councils, professional advisory committee and at quarterly quality meetings. We have benchmark against provincial averages for clinical data determined from RAI-MDS.

Our staff were committed to supporting our residents, their families and each other through the past 2.5 years. Their response has been exemplary.

Timely & Efficient Transfers – Emergency Department Visits

  • The Home has continued to use best practices to keep our performance below the provincial average while managing family and resident expectations. We continue to work closely with our NLOT and physicians to try mitigate avoidable ED Transfers. The Home has collaborated with the Alliance Networking Group to share best practices.

Safe & Effective Care

We have monitored the proportion of long-term care home residents with a progressive, life-threatening illness who have had their palliative care needs identified early through a comprehensive and holistic assessment. The Home chose this indicator in our last QIP submission.

Our teams are also focusing on reducing the number of falls.

Service Excellence

We continue: Resident & Family Council representation on CQI committee, considering feedback from Resident Council and Family Council meetings as well as Ministry of long-term care reports, resident rights review at staff meetings, annual multidisciplinary reviews and daily interactions with residents, families and visitors in the home. We continue to integrate best practices.

Patient/Client/Resident Partnering and Relations

As an interdisciplinary team we look forward to partnering with our Resident and Family council to support our Quality Improvement Objectives listed in our action plan.

Contact Information

Eunyoung Kim, Designated Quality Lead