Risk Profile: Regulatory – Accreditation

Risk Profile: Regulatory – Accreditation (PDF version)

Accreditation is an ongoing process of assessing healthcare organizations against standards of excellence to improve the quality of healthcare. Standards focus on providing quality care for patients covering a broad spectrum of health services. This document contains information entered by your peers in the Risk Register application to help you manage this risk.


  • Likelihood – 3.50
  • Impact – 3.63

The Risk Register allows for risks to be assessed on a five-point likelihood and impact scale, with five being the highest.

Key controls/mitigation strategies

  • Accreditation lead oversees accreditation related activities and coordination of accreditation project plan; the lead works in collaboration with leadership from areas of the hospital/organization in order to be successfully accredited
  • Develop an accreditation project plan for final 18 months prior to the scheduled survey, including:
    • Communication strategy (e.g. monthly ROP [Required Organizational Practices] related activities)
    • Comprehensive training program applicable to any discipline and all areas of the organization
    • Administration of accreditation required tools
    • Patient and family engagement
    • Leading practices and ROP awareness events plan
    • Evaluation, action and monitoring feedback from the previous accreditation survey
  • Develop infrastructure for sharing accreditation status updates, including a steering committee, ROP leads, self-assessment teams, working groups
    • Clearly define accountability for the various roles and responsibilities related to the accreditation process
    • Provide support to the teams allocated to standards and to the ROP leaders
  • Develop and implement a structured and coordinated Accreditation Sustainability Plan to maintain momentum on accreditation work between accreditation cycles across the organization
  • Annual review of accreditation standards by teams and implementation of strategies to address identified gaps


  • “Tip of the Week” sign-off for ROPs
  • ROP status update reports
  • Monitoring of standard sets
  • Regular meetings with ROP leads to ensure ongoing monitoring of compliance with ROP
  • Review of Accreditation Canada portal reports
  • Develop mock tracer training program; review and share findings at unit and ROP lead levels
  • Review ROPs at corporate, program and unit levels

[1] As of January 1, 2017

Note: information presented in this document has been taken from the shared repository of risks captured by HIROC subscribers participating in the Integrated Risk Management program.

© 2018 HIROC. For quality assurance purposes.