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Sustaining the Quality Improvement Effort ~ Healthcare Accreditation

Destination Spotlight

Accreditation Canada, founded in 1958, defines accreditation as one of the most effective ways for health service organizations to assess and improve the quality of their services (Accreditation Canada, 2009). Over the years, the concept of healthcare accreditation evolved from hospital standardization to the assessment of health services provided by any health organization, with the fundamental goal of improving the quality and safety of those services.

The beginnings of accreditation in health care can be traced back to the early 20th century, when Ernest A. Codman, M.D., first proposed the “end result system of hospital standardization” in 1910. Under this system, a hospital would track every patient it treated long enough to determine whether the treatment was effective. If it was found to be ineffective, the hospital would attempt to determine why, so that similar cases could be treated successfully in the future.

The “end result system” would become a stated objective of the American College of Surgeons, upon its foundation in 1913, spearheaded by Franklin Martin, M.D., a colleague of Dr. Codman. (Joint Commission, 2009)

The time eventually came to share the mission of health care accreditation on a global scale, so that health organizations everywhere could benefit from effective, evidence-based health care quality improvement initiatives. Recently, Accreditation Canada renewed its accreditation program for global healthcare with an emphasis on the “green” approach.

The “green” approach accentuates sustainability through the creation and renewal of a quality improvement culture; reduction in paperwork through increased automation; more objective assessments through mapping episodes of care; and increased staff engagement through self assessments and pulse questionnaires.

Qmentum International ~ Advancing Quality Improvement and Patient Safety

Accreditation Canada International began the development of the Qmentum International Accreditation Program in 2007. An International Advisory Committee representing countries from the Middle East, the Caribbean, Europe, and South America and global pilot projects ensure that the program is culturally sensitive and adapted to country-specific legislation and regulation. The new program was launched in early 2010.

The accreditation program consists of an innovative step-by-step approach to quality improvement that raises the bar for quality and safety of health care organizations irrespective of their starting point on the quality journey. Any health organization can use the program, regardless of what step it happens to be in terms of organizational structures, processes and performance.

The program builds on the experiences and successes of proven Accreditation Canada International programs and focuses on

  • Quality Improvement
  • Patient Safety
  • Risk Assessment and Mitigation,
  • Performance Measurement
  • Accountability

Program Features

Features of the program include renewed and new standards of excellence; a roadmap for achieving improved quality; a customized on-site survey plan; an in-depth self-assessment and on-site survey process; performance measures; the use of tracers or episodes of care to assess quality at various interfaces within the health organization and system; and an accreditation award representing the organization’s level of performance at the time of the survey.

One of the program’s most valuable innovations for health organizations are the built-in features for customization while using rigor in the development and implementation of standards and survey assessment techniques.

The action plan for quality and safety improvement reflects client organizations’ level of readiness stated in the Readiness Assessment Report that is delivered to clients after a thorough on-site gap analysis. This plan addresses critical success factors such as establishing basic structures, policies and procedures, developing standardized processes, and monitoring and measuring outcomes.

The accreditation program assesses quality across the organization using eight dimensions that define quality by measuring the organization’s compliance vis-a-vis: population focus, accessibility, safety, worklife, client-centred services, continuity of services, effectiveness and efficiency.

Each criterion in the standards is linked to one of these eight quality dimensions. Thus important quality elements, for example worklife (quality working environment) and patient safety, are integrated into the program’s quality and performance measurement framework and provide a reading of the organization’s quality and safety performance.

Another key component is the focus on regular interaction and communication with client organizations throughout the accreditation cycle. This ongoing liaison enables Accreditation Canada International to work closely with organizations to address critical areas, assist with action planning, and monitor progress. The emphasis on communication is further underlined as health organizations are encouraged to consider input from leadership, front line staff, patients, and other stakeholders when important decisions need to be made.

Automated measurement tools are an integral part of the program and offer greater and more efficient data exchange, improved standardization and objectivity, and less paperwork. This allows Accreditation Canada International to quickly capture information from both large multi-site and smaller single-site organizations.

An innovation which will be offered within this program in the next version is the International Patient Standard that aims to enhance safety through standardization in the transfer, admission, treatment, discharge and after care of the international travelling patient.  The purpose of the International Patient Standard is to increase quality and safety for international travelling patients at specific transition and treatment points where they may be exposed to particular risk.

Program Assessment Techniques ~ Mapping an Episode of Care

Mapping an episode of care (via tracers) is the method used by surveyors during an on-site survey to evaluate an organization’s compliance to standards. It is a process of following a client’s path from entry to discharge and follow up in a healthcare environment and includes elements such as client assessment, investigation, treatment, discharge and follow up.

During an episode of care, surveyors use direct observation and interaction with a wide variety of staff, clients, and stakeholders to gather evidence about the quality and safety of care and services in a particular service area. Mapping an episode of care is used to evaluate clinical (direct client care) processes. Managers can also use this tool on their own to conduct “mock mapping” to assess quality within their organizations without the use of external surveyors.

This method is flexible and responsive, and may include meeting patients and families. It is important to remember that surveyors are not evaluating individual performance – they are observing processes and procedures to assess compliance with the standards.

Mapping an episode of care has four components:

  • Reviewing files and documents:  Surveyors review client, human resource, or other files and documents, according to the tracer they are conducting.
  • Talking and listening: As they move through the organization during the on-site survey, surveyors talk to staff, clients, families or others who may be relevant to the tracer.
  • Observing: Surveyors observe processes, procedures, and direct care activities in the service areas.

Recording: Surveyors record their perceptions and important points about what they see, hear, and read.

Program Rigour ~ Performance Measurement and Quality Performance RoadmapThe Quality Performance Roadmap is an online tool available via the Client Organization web-portal that client organizations use to structure their accreditation journey and communicate with Accreditation Canada International. The Roadmap is a comprehensive electronic record of accreditation activities and results maintained throughout the accreditation cycle.

The Roadmap helps a client organization identify and address areas for improvement, and track progress. Through the Roadmap, the client organization can:

  • View aggregate results of the self-assessment questionnaires.
  • View indicator and instrument data.
  • Identify strengths and prioritize areas for improvement based on results, high-risk areas, and organization priorities.
  • Review the standards to identify areas requiring improvement.
  • Develop and prioritize action plans to address areas for improvement.
  • Submit evidence of action taken to Accreditation Canada International.

The Roadmap shows clients’ results from self-assessment questionnaires, indicator and instrument data and evidence of action taken that has been submitted by the client organization.

Results are color-coded using green, yellow, and red flags to indicate priorities for organization accreditation teams to review the applicable standards, identify gaps, and develop action plans. To facilitate this process, links to the relevant standards for each flagged item are provided.

Often clients apply the Quality Performance Roadmap and its quality dimensions to align their organizations’ balanced scorecard and use it as a dashboard instrument for performance measurement. Clients also use these metrics for internal benchmarking purposes.

Program Value

The time, commitment, and resources that an organization invests in the accreditation process provide an invaluable return in promoting and improving quality and patient safety, increasing accountability, and optimizing the effective use of available resources.

Sustaining the new quality improvement culture through staff engagement, regular knowledge transfer to new staff, capacity building through the trainer concept, and continued leadership support is a key value that clients gain from Accreditation Canada International’s new accreditation program.

It is important to remember that Accreditation Canada International does not consider accreditation as a “pass or fail” system. On the contrary, it considers accreditation as a means rather than an end that helps health organizations achieve success and become leaders in their field, to the benefit of the organization itself, the health system, and health care patients worldwide.


Accreditation Canada. (2009). Message for the Public. Retrieved December 9, 2009, from

Joint Commission. (2009). About Us – A Journey Through the History of The Joint Commission. Retrieved December 9, 2009, from

About the Authors

Accreditation Canada International specializes in exporting health accreditation expertise to global frontiers. Accreditation Canada is a not-for-profit, independent organization that provides national and international health and social service organizations with a voluntary, external peer review to assess the quality of their services based on standards of excellence. Accreditation Canada’s programs and guidance have been helping organizations strive for excellence for over 50 years. To learn more about Accreditation Canada International programs, education opportunities, consultation services, or organizations we have accredited around the world, visit or e-mail

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