Why participate in Accreditation? What is Accreditation? An on-going process that Healthcare organizations use to evaluate and improve the quality of their services. The goal of Accreditation and the on site survey is to track/observe clinical and administrative processes. Through evidence submission and the course of doing an onsite visit, surveyors will evaluate the organization and grant an Accreditation Award. Simply put Accreditation Canada conducts an extensive audit of our organization Surveys the organization to ensure patients are receiving the best quality of care Demonstrates our commitment to excellence Provides recognition that we meet national standards of quality Demonstrates accountability and transparency Why participate in Accreditation?

TBRHSC Accreditation Award 97.2% Accredited with Commendation Awarded 2 Leading Practice Awards New Accreditation Award Granted Accreditation Canada has applauded our leadership, staff and accreditation team members for their dedication to the provision of safe quality health services. They have also recognized the organization’s determination and commitment to ongoing quality improvement Though TBRHSC has exceeded in many areas Medication Reconciliation has presented some challenges for the organization. Currently measures are in place to address this priority area. One of the measures adopted is inclusion of Medication Reconciliation as a Quality Improvement Plan Priority, this will ensure quarterly monitoring of process completion. Moving Forward

Accreditation Cycle/Steps   Step 1: Assemble Teams Create teams based on the services that the organization provides. These teams should consist of individuals whom have an understanding of the area which their team will be assessing and later creating an action plan for. The team will use the Accreditation Canada standards that best apply to the focus of the work done by their team Step 2: Self-Assessment The self-assessment is a structured process that helps organizations assess their current performance against the standards, determine which areas required more detailed review and follow-up, set priorities, and develop action plans to address areas needing improvement. Criteria will be flagged red, yellow or green. Those items identified as red flags will require immediate attention while the green flags will show where the criteria have been met. The areas deemed yellow will need to be addressed prior the next accreditation, however are not classified as high risk. Step 3: Action Plan Teams will create an action plan to address the criteria requiring attention as identified through the self assessment process. Step 4: On-site Survey and Award The on-site survey is an opportunity for surveyors to discuss the organization’s progress in addressing self-identified areas for improvement, and to share their expertise with organization staff. Depending on the size and complexity of the organization, the on-site survey may last between three and five days. From the information gathered during this visit along with evidence submitted an Accreditation Award will be granted. Accreditation Reports Accreditation reports are submitted by the organization at various times during the accreditation process. This procedure helps maintain an ongoing link between the organization and Accreditation Canada and shows the progress achieve throughout the process.