Accreditation

Accreditation measures the quality of our services. It shows that the care and services our CIUSSS provides meet standards of excellence. These standards serve to identify what we do well and where we can improve.

Accreditation Canada is an independent Canadian non-profit organization the works with healthcare institutions and users to assess the conformity of care and services.

The Qmentum accreditation program is available to public health and social service institutions in Québec. It is based on the standards defined by the Health Standards Organization (HSO) and approved by the Standards Council of Canada (SCC) on behalf of the Canadian General Standards Board.

There are specific standards to follow for each CIUSSS program, service or clientele to ensure the quality and safety of our care and services. There are also cross-sectoral standards for these objectives. Those standards apply across all departments and concern such aspects as infection prevention and control, medication management, and telehealth.

There are three levels of criteria: normal, high-priority, and required organizational practices (ROP). The ROPs must be in place because the directly affect the safety of users.

There are 6 categories:

• Safety culture
• Work life
• Medication use
• Infection prevention and control
• Communication
• Risk assessments

The accreditation process involves everyone in the organization, from the Board of Directors to healthcare and administrative personnel, to physicians, professionals, interns, volunteers, contractors, users and their families, and community partners.

The surveyors use the tracer method to evaluate conformity. A tracer is a means of following the progression of a user or an administrative process along the entire continuum of care.  During the visit, surveyors may come speak with you or your colleagues. They may also speak with users and their families. The goal is to understand the day-to-day functioning of your department.  They will look at certain clinical files and administrative documents, and directly observe how things are done in your department.  The surveyors base their results on what they have seen, heard, and read.

Following the visit by Accreditation Canada, the CIUSSS will receive a report.  The report provides a detailed assessment of conformities and non-conformities, as well as suggestions for potential improvements.  Accreditation Canada also sends a letter outlining the non-conformities for which the affected departments must implement an action plan.  The affected team will have a fixed period of time to follow up on the recommendations and demonstrate that they are making progress.