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


​Accreditation Canada

​​Accreditation Canada is the major national accrediting body for health care organizations in Canada. Accreditation Canada’s mission is to help health care organizations improve the services they provide. 

The accreditation program is voluntary and is recognized by provincial and federal funders of health services. Learn more at the Accreditation Canada website or by contacting us at accreditation [AT] rickhanseninstitute [DOT] org

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​Accreditation Canada Spinal Cord Injury Standards for Acute and Rehabilitation Services 

In 2012, the Rick Hansen Institute (RHI) partnered with Accreditation Canada (AC) to develop comprehensive and evidence-based standards for Spinal Cord Injury care in acute and rehabilitation settings.  The SCI standards are part of the range of Service Excellence standards that are available for organizations to use when they participate in  the Qmentum accreditation program.  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 standards are kept current thanks to regular revisions through national consultation with field experts.  

Hosting a site visit in 2017? Version 11 are available from the login part of this site.  If your site visit is in 2018, please refer to version 12 of the standards, also available here.

 If you are at one of the RHSCIR sites, and don't know your login information, please contact your RHSCIR local site coordinator. if you don't know who that is, please email clinical [AT] rickhanseninstitute [DOT] org.