Accreditation 101

Accreditation Canada 

Accreditation Canada is a not-for-profit organization that is dedicated to working with patients, policy makers and the public to improve the quality of health and social services for all. They work closely with health and social services organizations in Canada and abroad to develop a sustainable culture of improvement that betters safety and efficiency, working to save and improve lives.

What is Accreditation?

Accreditation provides us with an independent, third-party assessment of our organization using standards built upon best practices used and validated by organizations just like ours around the world.

Accreditation is an ongoing process of assessing health and social services organizations against standards of excellence to identify what is being done well and what needs to be improved.

It involves all members of our organization, from our Board of Directors to frontline staff as well as members of the community including patients and families and our community partners. It allows us to understand how to make better use of our resources, increase efficiency, enhance quality and safety and reduce risk.

Accreditation Canada works with more than 900 expert peer surveyors with extensive health care and social services experience and trained in Accreditation Canada’s customized, continuous assessment program. For more than 60 years, Accreditation Canada has been working with health, social and community service organizations to advance quality and safety.

• 31 Required Organization Practices (ROP)
• 14 Departmental Accreditation Teams

What does the Accreditation journey look like?

Accreditation Canada surveyors will be visiting all areas of our hospital from April 3rd- April 6th, 2023. During this visit, they will observe some committee meetings, conduct interviews, and follow both clinical and administrative processes through the hospital from beginning to end- this is called a tracer. During the tracer, the surveyors will review charts and documents, ask questions of staff, patients or visitors, observe processes, and record their findings.

How do we prepare?

Over the next several months, we will plan and prepare for our Accreditation visit. Preparation activities will include:

• Departmental Self Assessments and Action Plans
• Discussion and education at Lean Huddles
• Information sharing (via social media, posters, The Pulse, etc.)
• Mock tracer activities

Validate that our policies and processes conform with best practice standards
Confirm that we consistently follow standard work processes

Learn from industry experts as part of our on-going continuous improvement strategies

REMEMBER, ACCREDITATION IS OUR OPPURTUNITY TO SHOWCASE THE GREAT WORK THAT YOU DO EVERY DAY!