Learn About Accreditation

What is Accreditation?
How does Accreditation work?
Who are the surveyors?
How does Accreditation advance SCI care?
What about the Trauma Distinction program?
What is different about the SCI standards?
Why use the SCI standards?
What about Required Organizational Practices?​​​​​​​​


What Is Accreditation?

Accreditation is a process that organizations use to evaluate their services and enhance the quality of their services. Accreditation also provides recognition that an organization's services are meeting national standards of quality.

Accreditation Canada is the major national accrediting body for organizations across all health sectors in Canada. Accreditation Canada’s mission is to help health care organizations improve the services they provide. The independent, non-government, non-profit organization began in 1958 when health organizations called for national standards and an accreditation program.

Close to 900 organizations across 1,300 facilities in Canada and around the world have now joined as members and are currently accredited under Accreditation Canada’s Qmentum program.  The accreditation program is voluntary and is recognized by provincial and federal funders of health services. Visit the Accreditation Canada website to learn more or email us at accreditation [AT] rickhanseninstitute [DOT] org.

How does Accreditation work?

During a Qmentum accreditation survey, a team of trained Accreditation Canada surveyors visits the organization and conducts a number of interviews and observations to assess how their day to day delivery of care and services aligns with the standards of excellence set out by Accreditation Canada. An accreditation site visit is meant to be interactive, grounded in daily practice and reality, and is usually a very rewarding, validating experience for staff.

Who are the surveyors?

Surveyors are health care professionals from across the country, whose areas of expertise can range from administration to nursing to allied health.  Surveyors can range from directors and senior executives, to physicians and pharmacists. Their skills and experiences are matched to the teams and services being reviewed for the best possible fit. Surveyors volunteer their time with Accreditation Canada, so that health organizations across the country can share knowledge to improve services.

How does Accreditation advance SCI Care and how is RHI involved?

In 2012, the Rick Hansen Institute (RHI) partnered with Accreditation Canada (AC) to develop comprehensive and evidence-based standards for spinal cord injury (SCI) called the ACUTE AND REHABILITATION SCI STANDARDS OF CARE (SCI Standards). They are available on the login section of this website.

They were developed by a national Spinal Cord Injury Advisory Committee, with representation from experts in the field of SCI across the continuum of care as well as individuals representing health care providers.  

The intent of the SCI standards is to provide content that is specific to the work that you do every day, tailored to reflect the unique needs and journeys of care of SCI patients, and to incorporate current evidence-informed best practice in SCI care.  This specialized content helps you better pinpoint where to focus your efforts to advance practice, with a richness that you do not get from more generic service standards. 

RHI’s goal is to support sites participating in the Rick Hansen SCI Registry (RHSCIR) in using these new SCI standards, so that by the end of 2018, at least 50% will have included them in their Qmentum site visits. Broad implementation of these standards across Canada through policy and practice changes will help standardize and optimize care for people with SCI.

Through the Rick Hansen Accreditation Project, our approach is to:

  • Promote the advantages of using the SCI standards
  • Provide practical, easy to use tools  to seamlessly integrate the SCI standards in your existing Qmentum preparation processes
  • Develop and continue to evolve practice improvement tools and guides to help you address the most common areas for improvement that arise from the standards
  • Connect sites to share ideas, learn from the successes of their peers, and stay up to date on how the accreditation program evolves over time

Read more about how the standards were developed.

Find out more about the Rick Hansen Accreditation Project.

What about Trauma Distinction?

In addition to the Qmentum accreditation program, Accreditation Canada recently launched a number of “distinction” programs that organizations can apply for.

Distinction is on a separate, independent cycle from your regular Qmentum accreditation: it’s every 2 years, with different deliverables and milestones.  Rather than recognizing a site as meeting standards of best practice, this is an award as a centre of excellence, an innovator and leader in the field. 

Distinction is awarded for an area of specialized care, rather than to the entire organization like Qmentum accreditation is.  At this time, Accreditation Canada has a distinction program for stroke care that is already actively used, and is also working to release a Trauma distinction program in collaboration with the Trauma Association of Canada (TAC), which is targeted for September 2014.

The core elements of the distinction program are:

  • Meeting national standards of excellence
  • Implementing evidence-based protocols
  • Achieving performance indicator thresholds
  • Showcasing projects that demonstrate excellence and innovation

The Trauma distinction program will focus on trauma care throughout the continuum, as an integrated network, effectively following the entire journey of trauma patients, from pre-hospital care, to emergency care, critical care, acute and subacute care, and through to rehabilitation and reintegration into the community.  Access and flow through all of these transitions is an integral component of understanding and evaluating the patient journey to recognize true excellence and innovation.

The National Working Group on Access to Care and Timing is currently working on selecting a set of standardized indicators to describe the journey of care of traumatic SCI (tSCI) patients through the continuum, with the intent to improve overall system functioning, and align with the Accreditation Canada Trauma distinction program.

What is different about the SCI Standards?

The Qmentum accreditation program is designed to focus on quality and safety throughout all aspects of an organization’s services—from governance and leadership to direct care and infrastructure—to benefit patients, clients, residents, staff and volunteers.  To that end, Qmentum provides a wide variety of service excellence standards that describe best practices at the point of care in a multitude of different services, settings and populations. 

The Spinal Cord Injury standards that Accreditation Canada developed in partnership with Rick Hansen Institute are part of the range of Service Excellence standards available for organizations to use.  Like all other Service Excellence standards, they focus on the essential components of safe and effective health care, based on five attributes of excellence—clinical leadership, people, processes, information, and performance.

The latest version of the standards, version 10, was released in January 2015 for use in site visit surveys in 2016. Sites being visited in 2017 should use version 11. Both versions are available on the login section of this website.

Why use the SCI standards?

The SCI standards were developed with the intent to provide content that is specific to the work that you do every day, tailored to reflect the unique needs and journeys of care of SCI patients, and to incorporate current evidence-informed best practice in SCI care.  This specialized content helps you better pinpoint where to focus your efforts to advance practice, with a richness that you do not get from general-population service standards.

At a broader level, the SCI standards will help standardize and optimize care for people with SCI as more and more organizations across Canada adopt them into their practice, helping to establish Canada as a global leader in the field.

To ensure that the SCI standards are grounded in daily practice and reality, and are both applicable and objectively assessable across diverse SCI care settings, Accreditation Canada worked with four Canadian centres to pilot test the standards and incorporate the learnings before releasing them for use.  Many thanks to: Glenrose Rehabilitation Hospital, AB (Rehab SCI Standards); Ottawa Hospital, ON (Acute SCI Standards); Capital Health, Halifax, NS (Acute and Rehab SCI Standards); Saint John Regional Hospital, NB (Rehab SCI Standards). 

Since then, other centres have adopted the newly released SCI standards to be part of their next Qmentum site visits.  Capital Health achieved impressive results in both Acute and Rehab SCI standards in their 2013 Qmentum site visit. To date, sites using SCI standards to prepare for site visits in 2014 include:  Victoria Hospital at London Health Sciences Centre (Acute SCI), Toronto Rehabilitation Institute – Lyndhurst (SCI Rehab), and Toronto Western Hospital (Acute SCI).

These pilot sites and early adopters have shown that the SCI standards are a good fit not just for centres that have dedicated SCI units, but they are just as valuable for units with a mixed patient population.  If your organization provides care to SCI patients on mixed-population units that also provide other critical care, surgical or rehabilitation service, you may get the best value from the accreditation process by using both the SCI and the general-population version of the standards. 

RHI has developed some tools to help you align the SCI standards to other commonly-used general-population standards for acute and rehabilitation, so that preparation can be seamlessly integrated, with no significant workload increase by the addition of the SCI standards.

To get started, we encourage you to have a look at:

SCI Acute Standards compared to Perioperative Standards at a glance

SCI Rehab standards compared to Rehabilitation Standards at a glance

What about Required Organizational Practices?

Required Organizational Practices, or ROPs, are evidence-informed practices that address high-priority areas that are central to quality and safety. Accreditation Canada defines an ROP as an essential practice that must be in place to enhance patient/client safety and minimize risks.  Examples are medication reconciliation, pressure ulcer prevention, and educating patients about their role in safety.

ROPs are categorized into six patient safety areas: Safety Culture, Communication, Medication Use, Worklife/Workforce, Infection Control, and Risk Assessment. The ROPs are embedded in the standards, with common language across different services.  The same ROPs that apply to the general-population standards for acute (i.e. periop, critical care) and rehabilitation settings also appear in the SCI standards, with the same definitions and tests for compliance, thereby helping your SCI teams prepare together with the rest of the organization in a coordinated way that does not significantly add workload.

You can find the latest version of the ROP handbook for 2016 site visits here (click to download PDF file) . Sites being visited in 2017 can refer to the 2017 version of the ROP handbook, available here.