Complete guide to Canadian hospital accreditation — Accreditation Canada, Qmentum standards, Required Organizational Practices (ROPs), provincial requirements, survey process, and accreditation software.
Accreditation Canada uses the Qmentum program with ~50 Required Organizational Practices (ROPs). The accreditation cycle is 4 years. This guide covers Canadian hospital accreditation.
Qmentum Standards
| Standard | Description | ROPs |
|---|---|---|
| Governance | Board, leadership, quality improvement | 3 |
| Infection Prevention | IPC programme, hand hygiene, sterilization | 8 |
| Medication | Medication safety, reconciliation, high-alert meds | 6 |
| Patient Flow | Access, discharge, transitions | 4 |
| Communication | Patient communication, handover, disclosure | 5 |
| Risk Assessment | Falls, pressure injuries, VTE, suicide | 8 |
| Work Life | Staff safety, wellness, violence prevention | 4 |
| Service Excellence | Patient experience, complaints | 3 |
Accreditation Process
- Self-assessment: Hospital completes self-assessment against Qmentum standards
- Pre-survey: Submit pre-survey questionnaire and documentation
- On-site survey: Surveyors visit for 3-5 days — observe, interview, review
- Surveyor evaluation: Surveyors evaluate compliance with standards and ROPs
- Survey report: Accreditation Canada issues report with accreditation decision
- Follow-up: Hospital addresses any conditions or recommendations
- Next cycle: Begin preparation for next 4-year cycle
Key ROPs
- Patient identification: Two identifiers for all interactions
- Medication reconciliation: At admission, transfer, and discharge
- Hand hygiene: Compliance with hand hygiene protocols
- Falls prevention: Risk assessment and prevention measures
- Pressure injury prevention: Risk assessment and prevention
- VTE prophylaxis: Risk assessment and appropriate prophylaxis
- Suicide risk assessment: For at-risk patients
- Disclosure: Disclose adverse events to patients and families
Frequently Asked Questions
- What is Accreditation Canada?
- Accreditation Canada is the national accreditation body for Canadian healthcare organizations. It uses the Qmentum accreditation program with standards covering: governance, infection prevention, medication, patient flow, communication, and more. Accreditation is voluntary but most Canadian hospitals participate. The accreditation cycle is 4 years with on-site surveys.
- What are Required Organizational Practices (ROPs)?
- ROPs (Required Organizational Practices) are high-priority practices essential for patient safety that all accredited Canadian hospitals must implement. There are ~50 ROPs across categories: patient safety culture, communication, medication safety, infection prevention, risk assessment, and work life. ROPs are assessed during on-site surveys and must be met for accreditation.
- How does the Qmentum survey process work?
- The Qmentum survey process: 1) Self-assessment — hospital completes self-assessment against standards, 2. On-site survey — surveyors visit for 3-5 days, 3. Surveyor evaluation — surveyors observe practice, interview staff and patients, review documents, 4. Survey report — Accreditation Canada issues report with decision (accredited, with condition, not accredited), 5. Follow-up — hospital addresses any conditions.