Quality Report
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Overview
Year Ending: December 31, 2025
Eunyoung Kim
Position: Clinical Informatics / RAI Coordinator
Bethany Lodge has identified the following key priority areas:
Resident/Client Experience – Improve communication, recreational programming, engagement with residents and families, and overall comfort and environment.
Palliative Care – Deliver holistic, person-centered care for residents at end-of-life.
Equity and Indigenous Health – Advance culturally safe care and inclusive practices, supporting all groups including First Nations, Inuit, and Métis residents.
Safety and Risk Management – Strengthen proactive, real-time safety monitoring.
Laundry and Housekeeping Services – Enhance efficiency and quality to maintain a clean, safe, and comfortable environment.
Interior Environment – Ongoing re-decoration and replacement of furnishings to create a welcoming, homelike, and safe setting for residents.
Objectives and Protocols:
- Person-centered care planning and regular care conferences.
- Staff education in cultural safety, palliative care, and patient safety.
- Standardized laundry and housekeeping protocols with monthly quality checks.
- Phased interior re-decoration plan, including new furnishings and updated décor.
- Continuous monitoring through the CQI Balanced Scorecard.
Priority areas were identified through:
- Annual resident/family survey results.
- Feedback from Resident and Family Councils.
- Analysis of clinical and operational performance indicators.
- Recommendations from the CQI Committee, including multidisciplinary staff and council Chairs.
This ensures priority areas reflect both resident experience and organizational performance objectives.
Monitoring: Tracked via CQI Balanced Scorecard, monthly departmental reports, and quarterly CQI meetings.
Adjustments: Data-driven changes implemented in real time based on resident and staff input.
Communication: Updates shared via newsletters, staff huddles, and quarterly council meetings.
Survey Date: October 15, 2025
Key Findings:
| Area | Noted Concerns | Resident / Family Rating | |
| Laundry Services | Timeliness & Quality | Residents | 82% satisfied |
| Housekeeping | Odours & Cleaning Consistency | Families | 83% satisfied |
| Communication | Updates on resident health | Families | 80% satisfied |
| Recreation | Weekend spiritual activities | Residents | 84% satisfied |
| Interior Environment | Furnishings and décor | Residents | 85% satisfied |
Communication of Results: Findings shared on November 1, 2025, with residents, families, Resident and Family Councils, and staff.
i. Improvements Based on Survey Results
Laundry Services:
Introduced new scheduling system and standardized quality checks.
Outcome: Reduced delays and misprocessed items; resident satisfaction improved.
Housekeeping Services:
Revised cleaning protocols with a focus on high-touch areas.
Monthly audits implemented.
Outcome: Improved cleanliness ratings in surveys; odours effectively managed.
Interior Environment:
Implemented phased re-decoration and replacement of furniture in resident rooms and common areas.
Introduced homelike décor, updated flooring, and comfortable seating.
Outcome: Residents report increased comfort, safety, and satisfaction with the environment.
ii. Other Quality Improvement Initiatives
Communication: Fostered open communications with residents/families.
Recreation: Expanded activities to include enhanced religious/spiritual programming and weekend engagement.
Palliative Care: Annual Palliative Performance Scale assessments completed; staff education refreshed.
Safety: Introduced real-time incident reporting and safety huddles.
iii. Roles of Councils and CQI Committee
Resident and Family Councils: Provide feedback on CQI activities.
CQI Committee: Led implementation, monitored outcomes, and ensured accountability.
iv. Communication of Actions
Actions and outcomes shared via: Quarterly CQI meetings, Family/POA Electroninc Communications; Resident and Family Council meetings (March 15, 2026)
A copy of this report is provided to the Residents’ Council and Family Council.
Published on the Bethany Lodge website in compliance with Section 168 of Reg 246/22.
Bethany Lodge remains committed to continuous quality improvement, using evidence, feedback, and collaboration to enhance care, services, the resident experience, and the home’s physical environment. Our goal is to maintain the highest standard of person-centered, compassionate care in a safe and welcoming environment.
Contact Information
Eunyoung Kim, Designated Quality Lead