Accreditation Self-Assessment: Frequently Asked Questions

What is self-assessment?

  • The most common first step in the Qmentum accreditation process, self-assessment provides a snapshot of where an organization currently stands in relation to the standards.
  • Self assessments are delivered as an online multiple choice questionnaire.
  • Questions relate directly to the criteria in the standards that surveyors will evaluate.  
  • Self-Assessments are for your team’s benefit and learning – all responses are anonymous and surveyors do not have access to the results.  

How are the self-assessment standards selected?

  • For the most part, Accreditation Canada provides direction on which standards are expected for which settings
  • When there is more than one set of standards that could apply, medical and operations leaders typically select the standards that best fit their teams’ work.

Why do we do self-assessment?

  • Allows us to identify our best practices and areas of strength.
  • Allows us to identify areas that we can improve.
  • Helps us prioritize what to work on for best impact to quality and safety
  • Helps us develop a roadmap for improvement, with action plans and links to existing initiatives

Who takes part in self-assessment?

  • Try to include those closest to the care that your team delivers every day: clinical staff and physicians are the experts in the day-to-day practices for their areas.
  • As much as possible, try to limit how many questionnaires to ask people to fill out

How do teams participate in self-assessment?

  • Self-assessments are completed through an online survey
  • Your accreditation or quality lead will communicate the specific link, login information and deadline for your team’s self-assessment
  • You don’t have to complete in one sitting: you can save your responses and go back later to finish. Total time can be somewhere between 30 to 60 minutes.

What do we do with self-assessment results?

  • Each team receives a summary report that highlights areas of strength and suggested areas for improvement
  • Teams use the results to choose what they will work on leading to their site visit
  • Common themes may also be identified for a coordinated improvement strategy