Regulatory – Accreditation

Accreditation is a continuous process of assessing healthcare organizations against standards of excellence to improve the quality of healthcare. Standards focus on key elements to include for quality patient care covering the broad spectrum of health services. Risks related to accreditation include being assessed as not receiving accreditation at an expected level. This document contains information entered by HIROC Subscriber healthcare organizations (acute and non-acute) in the Risk Register application to help you in your assessment of this risk.

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 organization to be successfully accredited.
• Develop an accreditation readiness plan prior to the scheduled survey, including:
  • Communication strategy (e.g., monthly Required Organizational Practices (ROP) related activities)
  • Leading practices and ROP awareness events plan
  • Comprehensive training program applicable to any discipline and all areas of the organization
  • Administration of accreditation required tools
  • Patient and family engagement (e.g., feedback from advisory councils)
  • 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 cycles across the organization
• Where possible, limit other operational work and projects to allow capacity
• Annual review of accreditation standards by teams and implementation of strategies to address identified gaps
• Partner with other healthcare organizations for best practice sharing (e.g., policy, regulatory requirements)
• Obtain feedback on lessons learned post accreditation to adjust plan and preparation for next Accreditation Survey.  
• Develop mock tracer training program; review and share findings at unit and ROP lead levels

Monitoring / Indicators

• Number of ROP’s met and status update reports at corporate, program and unit levels 
• Number of “Tip of the Week” sign off for ROPs
• Regular meetings with ROP leads to ensure ongoing monitoring of compliance with ROP
• Monitoring of standard sets completion
• Develop mock tracer training program; review and share findings at unit and ROP lead levels 
• Monitor project management metrics
• Manual audits of specific accreditation standards (e.g., medication reconciliation)
• Board committee reporting (e.g., quarterly reports of care risks, accreditation compliance scorecard)