Accreditation is an ongoing process of assessing Circle of Care against national and global standards to identify our strengths and areas for improvement. Hospitals, doctor’s offices, seniors and residential homes, rehabilitation centres, home care agencies, medical labs, health education programs, and many other health care settings go through the process of Accreditation.

Accreditation helps organizations like ours:

• Understand how to make better use of their resources
• Increase efficiency
• Enhance quality and safety
• Reduce risk
• Highlight to our clients and community that we are an organization that continuously evaluates and re-evaluates our practices in order to ensure our work is high quality and aligns with best practices

Earning the Accreditation Canada seal is a sign that an organization has worked hard to meet standards related to safe, high-quality care.

A Required Organizational Practice (ROP) is a mandatory process we must have in place to reduce risks, improve client and staff outcomes, and be Accredited with the highest standing.

The following are the ROPs associated with each standard:

Infection Prevention and Control (IPAC)

2.5.1. The organizational leaders are accountable to demonstrate improvement in hand hygiene practices as part of the organization’s infection prevention and control program.
2.6.1. Teams ensure medical equipment is cleaned and low-level disinfected to minimize cross-contamination and mitigate the risk of transmission of health care associated infections.
2.7.23. Processes for cleaning, disinfecting, and sterilizing medical devices and equipment are monitored and improvements are made when needed.

Service Excellence

4.2.2. The team leadership ensures the team demonstrates the required competencies to follow organizational procedures to prevent suicide.

Home Support Services

1.1.8. A safety risk assessment is conducted for clients receiving services in their homes.
1.3.8. The team follows the organization’s medication reconciliation procedure to maintain an accurate list of medications during care transitions.
1.4.2. Working in partnership with clients and families, at least two person-specific identifiers are used to confirm that clients receive the service or procedure intended for them.
1.4.14. Information relevant to the care of the client is communicated effectively during care transitions.

Medication Management

1.1.5. The organizational leaders ensure clinical teams adhere to a current do-not-use list of abbreviations, symbols, and dose designations in all medication-related communication.
1.1.6. The organizational leaders implement a risk mitigation strategy to safely manage high-alert medications.
1.17. The organizational leaders implement a risk mitigation strategy to limit the availability of and access to high-concentration and high-total-dose opioid formulations.

Leadership

2.1.10. Organizational leaders optimize client flow within their organization
4.1.5. A documented and coordinated approach to prevent workplace violence is implemented.
4.1.9. A documented and coordinated medication reconciliation process is used to communicate complete and accurate information about medications across care transitions.
4.1.11. Patient safety training and education that addresses specific patient safety focus areas are provided at least annually to leaders, team members, and volunteers.
4.2.2. A documented and coordinated approach to disclosing patient safety incidents to clients and families, that promotes communication and a supportive response, is implemented
4.2.3. A patient safety incident management system that supports reporting and learning is implemented.
4.3.8. A preventive maintenance program for medical devices, medical equipment, and medical technology is implemented.

Governance

3.1.12. The governing body demonstrates accountability for the quality of care provided by the organization.

When surveyors from Accreditation Canada visit us on-site from October 13-16, they may occasionally ask you a few questions about your work.

Please know that this is not a punitive process, and surveyors are not expecting perfection. Their goal is simply to understand how we work, ensure we’re following best practices, and see how we provide safe, high-quality care. They may ask about where you find information, how you escalate any concerns you might have, or how you carry out your role.

There will otherwise be no disruptions to your role during Accreditation.

Accreditation Bingo

As you reflect on how your program or service aligns with the Accreditation standards, we invite you to use our Accreditation Bingo activity. Not every section will be relevant to your day-to-day work – focus on the standards that are most applicable to your role and use them as a starting point for meaningful conversation and reflection.

Frequently Asked Questions (FAQ)

Please feel free to use the form below to submit any questions you have about Accreditation. We will put together a list of frequently asked questions and update this page in the near future.