The Steps to Accreditation

Step 1 - Self Assessment
Step 2 - Identify Areas for Improvement
Step 3 - Develop Action Plans
Step 4 - Implement Improvements
Step 5 - Site Visit
Step 6 - Sustainment

Step 1 - Self-Assessment

Typically, most organizations will begin the first step in preparing for accreditation by conducting a self-assessment. Self-assessments are online surveys that ask teams to rate how they think their services and day-to-day practices meet Accreditation Canada's requirements.

It's about what you do every day

In order for the self-assessment to give useful information, ideally it should be inclusive of the voice of those people who touch patients' lives every day, particularly front line staff and physicians. The more open, honest responses an organization can get about how its day-to-day practices compare to the standards, the better it can identify what needs improvement well in advance of the site visit.

Self-assessment responses are anonymous, and Accreditation Canada does not share them with the accreditation surveyors. The results belong to your organization as data for quality improvement. What is more, all responses are rolled up together and reported as aggregate flags, so that no one individual can be identified for how they responded.

How does my team take part?

The accreditation self-assessment is an online survey with privacy protection to ensure your anonymity. All that is needed is a willingness to take part and a computer with internet access. Your accreditation or quality team lead will provide the specific link and login information that will take you to the self-assessment questionnaire specific to your team.

Questionnaires can take between 30-45 minutes to respond. If your team is using more than one set of standards, i.e. SCI acute and Perioperative, some staff may be assigned to complete the SCI questionnaire, and some to complete the Perioperative one, so that no one has to complete more than one.

The self-assessment questionnaire is worded exactly as the standards that apply to your team. The questions ask about a variety of different aspects of how your team functions, some that may apply to all team members, and some that may be more discipline-specific. Your accreditation lead may recommend using the "not applicable" option for practices outside one's role, rather than making a best guess, so as to not skew results.

Get the How-To

Looking for some key messages to help you talk to your teams about participating in the self-assessment? Check out some Frequently Asked Questions here. You can also download a printable PDF version of the Frequently Asked Questions for more information on the self-assessment step.

Wondering how your team's online survey will look and behave? Download the User Guide: Completing the Accreditation Online Self-Assessment to get detailed step-by-step instructions with screen prints.

What happens next?

The online self-assessment for your team will stay open for response until the deadline specified in the invite that you will receive from your team's accreditation or quality leader. After the closing date, results will be automatically calculated into an aggregate report that your accreditation or quality leader will share with your team.

The results will provide the basis for your team to choose the top priority areas for improvement that you will work on together in preparation for the site visit.

Step 2 - Identify Areas for Improvement

Learning from Self-Assessment Results

Once the self-assessment questionnaires close, the second step in accreditation begins: learning from the results and identifying areas for improvement.  Teams receive their own results, which summarize how well staff and physicians feel that the teams’ current practices meet the standards as stated. Typically, teams meet to discuss their results, explore which items hold actual, feasible opportunities for improvement, and prioritize the improvement areas that have the potential to make the highest impact on quality and safety. 

How are self-assessment results calculated?

The algorithm that Accreditation Canada uses to calculate the flags is as follows:

Responses of “don’t know” and “not applicable” do not factor into the flag calculation.

Red, yellow, green… what does it all mean?

Most teams’ results will look like a traffic light gone awry, with some line items in green, others in red, and a fair bit of yellow thrown into the mix. Not to worry: this three-colour rainbow is perfectly normal.  If your team’s report is based on a small number of responses (i.e. under 10), you’ll likely have more of the greens and reds, and fewer of the yellows. That is also perfectly normal. 

What matters is that the colours on the results report are just discussion-starters, a way to help teams prioritize where to focus next. Typically, flags suggest three different levels of compliance to the practice that the question asks about:

Green flag: likely high compliance – most respondents say we do this practice consistently, to best practice

Yellow flag: likely inconsistent compliance – respondents either do not agree on how consistently we do this practice, or it’s still a work in progress, with opportunities for improvement

Red flag:  likely low compliance – most respondents say we do not do this practice to the extent described in the standards

In essence, flags alert teams to where there may be some gaps, based on how staff responded to the questions, so that they can direct their attention to those areas and understand them better. What the flags by themselves do not tell us is the richer, more qualitative information that will allow a team to prioritize, commit to and carry out a journey of improvement. Typically, teams will draw most of their learning from this step in the accreditation process by meeting and discussing the flags in the context of their experience.

What to focus on?

Accreditation Canada defines three different tiers of priority in the standards that weigh into the overall accreditation award.  These three tiers can be very helpful to teams as they meet to review their self-assessment results.

Required Organizational Practices, or ROPs , are the essential “must-have” practices that need to be in place because, without these, patients and/or staff may be at risk.  Examples are medication reconciliation, pressure ulcer prevention, and educating patients/families about being active participants in care and safety. These are the items that carry the most weight into how surveyors evaluate the quality of services, and consequently, how Accreditation Canada assigns an accreditation award based on the surveyors’ findings.

ROPs are a natural first place to start identifying a set of “vital few” priorities for improvement.  Typically, teams will start by discussing these first, and treat any unmet ROP as the highest priority for improvement work, before anything else in the standards.

The next tier of priority in the standards is the one made up of the High-Priority criteria. These are all the other practices that address patient safety, risk management, ethics, and a culture of quality improvement. While they still contribute greatly to the overall quality and safety of services, they tend to be more general statements, as compared to the ROPs, and have guidelines rather than specific tests for compliance. 

High-priority criteria can make up more than half of a self-assessment’s total number of flags.  To keep the number of improvement priorities manageable, many teams choose to focus on high-priority criteria only after they have ensured compliance to the ROPs. 

The last tier of priority is made up of all the “Other” criteria in the standards that are neither ROPs nor high-priority criteria.  These tend to be the enabling systems that support teams in carrying out the practices described in the ROPs and high-priority criteria. Examples include having the right information systems, staffing mix, equipment and physical space.  While these criteria carry the least weight in how Accreditation Canada assigns the overall accreditation award, they impact team functioning and culture, and therefore tend to support other items (ROPs or high-priority criteria) that teams may already have identified for their action plan. 

Get the Tools

There is a great deal of content that is common between the SCI standards and the general population standards for acute and rehab settings, including the ROPs and their tests for compliance.  There is also some specialized content in both the SCI and general-population standards that will allow teams to learn some unique things about their practices. 

In collaboration with Accreditation Canada, RHI has developed some tools to help you adopt the SCI standards for acute and rehab care as part of your organization’s normal Qmentum preparation process, with as little impact as possible to your teams’ workload.

Learn about key differences between SCI Acute standards and general-population Perioperative standards.

Learn about key differences between SCI Rehab standards and general-population Rehab standards.

Want the best of both worlds? If your team has chosen to use both the SCI and general population standards, the templates below can help you quickly and easily consolidate the self-assessment results from both sets of standards into a single worksheet. These worksheets are available on the login section of this website.

The process of learning from the self-assessments and identifying improvement priorities sets the stage for the next steps in the accreditation preparation process, when teams begin to form their action plans and then subsequently implement improvements.

Step 3 - Develop Action Plans

Plotting out the roadmap

Once teams have used their self-assessment results to identify a set of “vital few” improvement priorities, the work begins to develop those priorities from “wish list” into reality.  During action planning sessions, teams will typically start attaching specific change ideas and action steps to each identified priority for improvement.  

A tool for you

Ultimately, the action plans are a tool for the team. You do not have to submit them to Accreditation Canada or share them with your surveyors during the site visit. They are your own internal roadmap to guide the implementation of those “vital few” improvements leading up to the site visit in a way that can be sustained well beyond. 

There is no right or wrong way to create an action plan: in fact, your team may already have some “tried, tested and true” ways of planning for and rolling out changes that make staff feel included and heard.  As a general guideline, though, in order for action plans to be specific enough to guide improvement, teams may want to include:

• Why: the specific criterion in the standards, or test for compliance that is currently a gap that needs to be addressed
• What: the change idea itself and action steps that the team is going to try
• Who: the key leads within the team that will ensure the action steps are done. A key lead may not need a formal leadership title; sometimes they are the subject matter experts on the team
• By When: specific timeframes for the major milestones in the action steps, so that the team can gauge progress over time.
• Measures: how the team is going to know that their change idea is working and is being sustained. Think of measures that can realistically be tracked over time, so that you can make assumptions on your progress based on more than just a pre- and post-implementation snapshot.  Also think of different types of measures that can tell you:
  • Whether the agreed-upon process is being followed consistently (i.e. the appropriate screener being done, the appropriate care plan being triggered by the screener), and
  • Whether you are seeing the desired results (i.e. reduction in undesirable events, improved patient experience, improved worklife…)
    
    

If your team does not already have a preferred format for documenting its action plans, here is a simple customizable template that you may find useful.

What’s next…

The majority of the work of preparing for accreditation consists of embedding the standards in day-to-day practices and making them part of how teams work every day.  Up until this point, teams have done the homework that allowed them to identify what needs improvement, and what change ideas they can try to achieve it. Now the hands-on work begins, with change ideas being tested, adjusted, and scaled in the real world. Now more than ever, staff and physician engagement is key to success.

Step 4 - Implement Improvements

Where the rubber hits the road

Now begins the heart-and-soul of why organizations do accreditation: embedding the standards in day-to-day practices and making them part of how teams work every day.  Up until this point, teams have done their homework to identify what needs improvement, and what change ideas they can try to achieve it.

This is the hands-on work of testing change ideas, adjusting them along the way to make sure they work as intended, and making them part of standard practice. Teams also think of how those new best practices can be sustained in the long term to keep improving quality and safety well after their surveyors are gone. 

Just as is the case with developing action plans, there is also no single “right way” to implement improvement ideas into action.  Your teams may already have some “tried, tested and true” change management and practice improvement processes.  As a general guideline, we encourage teams to consider some key principles:

• Engaging all the stakeholders
• Plan, Do, Study, Act… then do it all again!
• It’s really hard to manage what you can’t measure
  
  

Engaging all the stakeholders

When trying to improve a process, there is a wealth of people who know that process inside-out because they use it every day, or are touched by it, that can make amazing contributions if you tap into them.  The people who touch patients’ lives every day, frontline staff and physicians, will often come up with the most elegant solutions because they are grounded in hands-on experience.  But we also encourage you to consider how patients and families can provide input as your partners in care. Surveyors, after all, will look at processes from the patients’ perspective when they conduct tracers during the site visit, so knowing how patients and families experience those processes will give your team a definite advantage!

Plan, Do, Study, Act… then do it all again!

Testing out your change idea with a number of different scenarios and variables increases your confidence level that the change you will eventually go live with will actually work as intended and be sustainable. It will also help you anticipate any unforeseen effects, both upstream and downstream of the process you are trying to improve.

The PDSA model for improvement (Plan-Do-Study-Act) is a simple, intuitive way in which you can build on what you learn along the way and adjust your course to get where you want to be. By doing multiple quick rounds of PDSA tests that build sequentially onto each other, you are able to generate knowledge quickly and refine the process as you go.

It’s really hard to manage what you can’t measure

As you start testing different change ideas, think of how you are going to know that you are on the right track: 

• How will you know that the right processes are being followed consistently? I.e. are we doing the right assessments at the right time? Are the right care plans initiated? Do we document consistently?
• How will you know that you are getting the right outcomes? I.e. are our patients experiencing less harm? Are they more satisfied with their care? Are we able to send them home sooner? Do they fare better once at home? Do they get readmitted less often?
  
  

Also think of how your team currently gets together to talk about quality and safety, and build on that if at all possible. By regularly reviewing and discussing your process and outcome measures as a team, you can learn in-the-moment and course-correct as you go.

SCI Practice Improvement Resources

Most teams will have at least one priority for improvement on their action plan that is not unique to them, but is actually a common challenge in other centres.  By participating in the RHSCIR Registry and the SCI² online Community of Practice, you are linked with other centres across Canada that are also working on implementing the SCI standards into practice.   We want to help sites build as much as possible from everything that has already been learned elsewhere, by making it easier to share knowledge, tools and resources for everyone’s benefit.  In this section, which will continue to grow over time, you will find a one-stop-shop of resources to help you address specific criteria in the standards and draw from the experiences of other teams so that you don’t have to “reinvent the wheel”.

Download ROP fact sheets (one double-sided page each):

• Falls Prevention ROP
• Information Transfer at Transition Points ROP
• Medication Reconciliation at Care Transitions ROP
• Patient’s Role in Safety ROP
• Pressure Ulcer Prevention ROP
• Surgical Safety Checklist ROP
• Two Patient Identifiers ROP
• VTE Prevention ROP
  • VTE Prevention pre-printed orders exampleVTE Prevention pre-printed orders example

Watch for additional fact sheets on standards contents and requirements, and other practice improvement gems coming soon to help you translate the standards into living, breathing day-to-day practice.

What’s next…

As you get closer to the site visit, and turn your attention to the practical preparation work to host the surveyors, the next section will share ideas on how to make it a validating and enjoyable experience for all involved. Here you can find some tools to help you “put your surveyor hat on” and look at your programs and services through their eyes by becoming comfortable doing tracers. 

Step 5 - Site Visit

What to expect when you’re expecting… surveyors

We’re hosting a tracer… now what?

• A site host who knows how your team works and ensures surveyors have access to people and documentation
• Access to up to 5 client files (electronic or paper charts) who are willing and able to participate, and who represent the typical patient/client/resident mix of your team
• Access to front line staff and physicians to interact with the surveyor
• Access upon request to any documentation that your team refers to in the course of delivering care, such as practice guidelines, manuals, forms, pathways, patient education materials, policies etc…
• Examples of quality improvement in your team, i.e. indicators that you track, practice changes you made, initiatives you are working on…
• A quiet space where surveyors can review files, make phone calls, eat lunch as needed
  
  

Download a printable Site Visit Logistics Overview.

While surveyors will only trace 1-2 patient journeys in detail, they can, and quite often will, also approach other patients, clients and families that may be on the premises at the time of the tracer for a quick conversation about their experience interacting with your organization.  The two poster templates below can be customized with your team’s site visit date and time, to notify anyone on the premises that they may be approached by a surveyor.

Site visit notification poster – Powerpoint, landscape view
Site visit notification poster – Powerpoint, portrait view

The Site Host with the most

The site host is the main go-to person that surveyors will refer to while they are visiting your team and conducting tracers.  Typically, the program director or leader will accompany the surveyor to the tracer location, then hand off to a site host within the team who has hands-on knowledge of how the team works. Managers, educators, care coordinators, team leads all make excellent site hosts. If you are selected to be the site host, your role will be to:

• Receive the surveyor at your site/unit, and show them around the premises
• Describe the highlights of your team: mandate, volume of clients served, staff mix, case mix, key partners you work with…
• Provide the surveyor with access to client files for the tracer
• Take the surveyor to front line staff members to interview
• Provide access to other documents as requested (i.e. manuals, forms…)
• Step back, let the surveyor direct the tracer, and know that your team will shine

What information should I have ready? 

Surveyors will be so busy conducting tracers at the point of care, and talking to staff, physicians, patients and families, that they won’t have time to review any carefully-prepared evidence binders. Instead, they may request access to documents and written information at any time during their tracers.  One of the key responsibilities of the site host is to receive the surveyors’ requests for information, and to source those documents upon request, either directly or by reaching out to other people within the organization who hold that information.

Because tracers are inherently very fluid, there is no one definitive list of documentation to have on hand on the day of the site visit. Surveyors will mainly want to ascertain that team members have ready access to the tools, resources and information supports that they need, when they need them in the course of delivering care.  Therefore, the kinds of information requests that surveyors are most likely to make will be pertinent to the patient journeys that they are tracing, and in the context of how team members would normally access the information as part of the work they do every day.

Here are a few ideas of frequently requested documentation that your surveyors may want to see. Rather than collecting these into a binder, think of how your team currently accesses them.

• Transfer documents, both into and out of your team’s care
• Assessment tools and their related care plans, flowsheets
• Clinical Practice Documents like guidelines, policies, pathways, Standard Operating Procedures
• Training/orientation manuals for new team members (staff, physicians, volunteers)
• Patient education materials and resources
• Sources of feedback from your patients/families: patient experience survey results, compliments and complaints, examples of patient/family engagement…
• Indicators that your team tracks for ongoing improvement: think of both process and outcome measures, and how they are discussed as a team and used for improvement
• Corporate policies and other information resources (i.e. how to access Risk management, Ethics support…)
  
  

Making the best first impression

Here is a customizable visual prep tool with tips to help you prepare for welcoming a surveyor. The Word document can be customized so that you can add information, examples or images for your specific unit/team/site.

What’s next…

After the site visit, your organization will receive the surveyors’ feedback and observations, and will have an opportunity to address any areas that require follow-up before receiving your final accreditation award. In the next section, we will explore ways to learn from the surveyors’ report and keep the momentum alive for continuous improvement.  We will also provide regular updates on changes to the standards and share ways in which the SCI community of care can participate in improving the accreditation program and the content of the standards through opportunities for consultation and surveyor recruitment.

Step 6 -  Sustainment

They came, they saw, they rated… Now what?

An organization’s first opportunity to receive its surveyors’ feedback and observations will typically be on the last day of the site visit.  Surveyors may start their debrief with a short closed-doors session with the governing board and senior leadership, which is typically followed by an open debrief session for all staff and physicians.  This is an opportunity to hear about the surveyors’ findings in four broad areas of focus that are represented in the accreditation standards:

• Patient safety
• Quality improvement culture
• Ethics framework and supports
• Risk management
  
  

While surveyors will not usually give team-specific feedback in the on-site debrief session, they will typically present a summary of the overall standards ratings, including met and unmet Required Organizational Practices.  Surveyors will then go over the top strengths and areas for improvement in each of the four key themes above that they observed at the organization-wide level. 

The onsite debrief can also be an opportunity for the organization to express appreciation for all the work that teams did to prepare for and host the accreditation site visit, and to celebrate the continuing improvement journey and commitment to quality in everything we do. 

Before leaving the site visit, surveyors will typically present the organization with a copy of their preliminary report, with detailed ratings and specific findings for each of the standards that were assessed. The organization will then have between 5-7 business days to review the content and provide feedback to Accreditation Canada about any factual inaccuracies (i.e. wrong names of programs or locations), so that corrections can be made in time for the final report. 

Organizations will usually receive their final report and notice of forecasted accreditation award between 2-3 weeks after the site visit, once the surveyors’ preliminary findings have been reviewed by Accreditation Canada’s own independent review body, the Accreditation Decision Committee.  It is the Accreditation Decision Committee, and not the surveyors themselves, who assign the accreditation award level and determine which, if any, unmet criteria require formal follow-up and by which timelines. 

There are four possible levels of accreditation decision awards. Accreditation Canada describes each level as follows:

• Accredited with Exemplary Standing: for organizations that go beyond the requirements of Accreditation Canada and demonstrate excellence in quality improvement. This is the highest level of accreditation.
• Accredited with Commendation:  for organizations that go beyond the requirements of Accreditation Canada and are commended for their commitment to quality improvement.
• Accredited: for organizations that meet the requirements of Accreditation Canada and show a commitment to quality improvement.
• Not Accredited: the organization must make significant improvements to meet the requirements of the accreditation program.
  
  

To arrive at the accreditation award level fairly and objectively, the Accreditation Decision Committee uses the following algorithm, which takes into account compliance with Required Organizational Practices and High-Priority Criteria, as well as whether the organization conducted surveys of staff and providers’ Patient Safety Culture and Worklife Pulse (referred to as “Instruments” below) at least once every four years, with a sufficient response rate to be a representative sample.

The same algorithm is applied to all organizations undergoing accreditation, whether they are single-site, single-service organizations (i.e. independent rehabilitation facilities) or full-continuum, regionally integrated systems (i.e. Alberta Health Services, BC health authorities). To find out more about accreditation decision levels, download Accreditation Canada’s algorithm.

The accreditation award itself is typically not finalized for another five months after the site visit. This provides an opportunity for organizations that have unmet criteria to submit status updates to Accreditation Canada to prove that those gaps have been addressed and resolved. If, upon reviewing the status updates, the Accreditation Decision Committee deems that there is sufficient evidence to consider those criteria satisfied, the final accreditation award will take those new ratings into account.  It is therefore possible for an organization to be upgraded from a forecasted decision of “Accredited” to a final decision of “Accredited with Commendation”.

Status updates for unmet criteria or Required Organizational Practices can be submitted as a concise (under 4,000 characters!) narrative summary. Here are some ideas for what to include in a status update:

• the specific unmet criteria or tests for compliance and surveyor rationale that the status update addresses
• full description of the actions and activities that have been completed after the on-site survey to meet the above
• when the actions were completed
• impact of the actions, and how the actions will be maintained and evaluated
• planned activities are useful (“we will be…”) but not deemed to be evidence that the follow-up is met
• If the ROP or criterion is unmet at multiple locations or in more than one program, please provide evidence for each location or program, prefaced by the location or program name as a header
• Please spell out acronyms or abbreviations the first time they are used

Keep the standards alive

After the site visit, the work should ideally continue to embed the accreditation standards into the way we practice every day.  After all, the standards describe the evidence-based practices that make services excellent every day, for every patient. 

We encourage sites to continue using the SCI standards as a guide towards achieving a “constant state of readiness”. The toolkits and resources that you can find on the SCI² site are geared to help you keep the momentum for improvement and ensure that the practices described in the SCI standards are just part of what your site does every day, regardless of when your next accreditation site visits are going to be. 

Another way to keep the momentum alive is to stay abreast of changes to accreditation standards and requirements as they are introduced. Every year in January, Accreditation Canada publishes updated versions of the standards, which may include revised criteria or ROP definitions and tests for compliance. The latest version of the standards, version 10, which applies to site visits in 2016 onwards, was released in January 2015, and contains strengthened expectations around patient and family-centred care as an underlying philosophy, as well as revisions to a number of ROPs to make the tests for compliance more robust and observable. Download the new Version 10 standards here. If your site visit is in 2017, you will use version 11, also available here.

We encourage you to take the opportunity to disseminate the standards within your organization and proactively identify what changes in practices may be required in order to successfully build compliance into day to day processes, well in advance of your next site visits.

Make accreditation better

Accreditation Canada regularly reviews and updates various components of its Qmentum accreditation program and standards to ensure that the content stays current and relevant, and keeps raising the bar for quality and safety of care.  Typically, every set of standards is revised every 3 years. As the SCI standards were released in 2012, and revisions are typically every three years, the next revision is expected to take place in 2018.

The input of subject matter experts as well as process experts is crucial to ensure that the revisions are not only an accurate reflection of current best practice, but they are also realistic and objectively assessable during an accreditation site visit. Therefore Accreditation Canada will actively seek out representation and feedback from client organizations into the revision process by reaching out to surveyors, accreditation leaders, and experts who were involved in the original working group that developed the standards.    

As RHI worked in partnership with Accreditation Canada to develop the SCI standards, we will continue to be involved in any future revisions, and will reach out to the SCI community of care to solicit input along the way, both as working group members and through broad consultation.  If you receive an invitation to provide feedback on revisions to the SCI standards, we hope that you will take the opportunity to participate. 

To find out more about how you can be involved, contact accreditation [AT] rickhanseninstitute [DOT] org.

Become a surveyor

Are you a health care leader with a passion for advancing best practices in SCI care? Do you enjoy travelling, exchanging knowledge with like-minded professionals within and outside of Canada, and bringing that knowledge home to benefit your organization? Then RHI and Accreditation Canada want you to consider becoming a surveyor.

Surveying is a great way to network with other health care professionals and broaden your skills, while bringing home a wealth of ideas and practical resources to help your organization and the SCI community of care at large to continuously improve. Surveyors are health care professionals from a diverse range of expertise, both clinical and administrative, who volunteer their time with Accreditation Canada to conduct accreditation site visits and advise on the accreditation program overall. As an accreditation surveyor with subject matter expertise in SCI care, you will participate in surveys twice a year, visiting organizations that provide care to SCI patients both within Canada and around the world, and helping them raise the bar on quality. 

To learn more about becoming a surveyor, visit Accreditation Canada’s Surveyor Recruitment page.