Post-Webinar Update: FAQs

December 5, 2018

In Oct. 31, 2018, Accreditation Canada held a webinar to provide updates to organizations on Health Standard Organization (HSO) and Accreditation Canada programs and services. Thank you to all who attended and asked questions during and after the webinar. Answers to these, and other questions are provided below.  

If you have any other questions, please send them to Client questions will be used to help improve the content included on this page.

  Program Questions 

  1. What version of the standards will my organization be assessed on in 2019 and 2020?
    For both 2019 and 2020 surveys, organizations will be assessed against version 14 standardsThis version resembles version 12 standards (assessed during 2018 surveys), but includes the updates to Required Organizational Practices (ROP) introduced in version 13.1 of the Qmentum standards (‘Falls Prevention and Injury Reduction’ and ‘Medication Reconciliation at Care Transitions’) released earlier in 2018. 
  2. When will Version 14 standards be available on the client portal?
    Version 14 standards will be available on the client portal under Access Resources, Standards by January 2019. At this time, organizations will also be able to conduct self-assessments against version 14 standards.
  3.  Earlier in 2018, revised versions of the ‘Child, Youth, and Family Services’ and ‘Intellectual and Developmental Disabilities Services’ Standards were introduced as part of the version 13.1 standard release. When will surveyors begin to assess against these standards
    Organizations will begin to assess against these standards in January 2019. 
  4. What version of the standards should my organization self-assess against? 
    For organizations with a survey in 2019, there are two self-assessment options: 

    A) You can self-assess in your portal using the version 12 standards that are currently available to all clients. However, please note that you will be assessing on the older versions of the ‘Medication Reconciliation at Care Transitions’ and ‘Falls Prevention and Injury Reduction’ ROPs that
    will be updated in the upcoming January release of version 14 standards. The ROP crosswalk titled 2018 ROP Crosswalk V2 provides additional information on these revisions and can be found on your client portal.

    B) You can wait until January 2019, when version 14 of the standards will be available for all clients to self-assess against in the portal.
    For organizations with a survey in 2020, please self-assess against version 14 standards that will be available on the client portal starting in January 2019. 
  5. Will the Accreditation Decision Guidelines change for 2019?
    The Qmentum Accreditation Decision Guidelines will not change for 2019. The guidelines can be found under the Accreditation Resources tab on the existing client portal. 
  6. Will the Accreditation Decision Guidelines change for 2020?
    As noted on the Oct. 31 webinar, there will be no new Decision Guidelines introduced in 2019. However, we are always looking for opportunities to improve our program and its associated components, including the Decision Guidelines. While there are no current plans to revise the 2020 Decision Guidelines, any changes or revisions will be shared with organizations via this landing page and through other communication channels as they become available.  
  7. What supporting materials are available to assist organizations with surveys in 2019 and 2020? 
    A ROP crosswalk and handbook will be released along with version 14 standards in January 2019.  
  8. Will there be any changes to Required Organizational Practices (ROPs) in 2019?
    There are no new or revised ROPs for organizations with surveys in 2019. Organizations with surveys in 2019 will be assessed against the Fall Prevention and Injury Reduction and Medication Reconciliation ROPs that were introduced in 2018. In 2019, our affiliate organization, Health Standards Organization (HSO) will be reviewing several ROPs. More information will be provided on these revisions as they become available. Any updates to ROPs introduced in 2019 will not apply to organizations with surveys in 2020.  
  9. What is happening with Assessment Manuals?
    We are working in partnership with HSO to obtain feedback on assessment manual prototypes. We will provide updates on assessment manual development through this landing page and on upcoming webinars as they become available.  
  10. What is happening with Attestation? Will this assessment method be available in 2019? 
    Due to the delay of the new IT platform and additional work required to ensure a smooth operationalization of this assessment method, we are unable to offer Attested Self-Assessments to organizations in 2019 on a mass scale. However, we are continuing to test this method with organizations throughout 2018 and in 2019.


Patient Surveyor Questions 

  1. What is a patient surveyor?
    Surveyors are reviewers who assess the performance of health organizations against standards of excellence and identify opportunities to achieve improved performance. As members of the survey team, patients have a complementary role that is conducted through the following tasks:
    – Assessing priority criteria that have been considered to be important in the implementation of PCC spanning across elements of the leadership, governance and service standards;
    – Leading the patient/resident/family engagement focus group; 
    – Participating in the leadership and governing body discussions; 
    – Conducting, in partnership* with other surveyors, an administrative tracer on quality improvement and clinical tracers on episodes of care selected in collaboration with client organizations (*discussions with staff/leaders will happen together and the patient/resident/family discussions will happen separately); 
    – Providing advice to other surveyors on the interpretation of PCC criteria and assessment of organizational practices and reflecting back to the organization the perceptions and observations, from a patient perspective, regarding exemplary practices and opportunities to improve the culture and practice of PCC and engagement.  
  2. How can I include a patient surveyor on my next accreditation survey?
    If you are interested in including a patient surveyor on your next accreditation survey, please reach out to your Accreditation Lead or Coordinator.  
  3. Is the participation of patient surveyors on surveys optional?
    Including patient surveyor on your accreditation survey is currently optional.  
  4. Does a patient surveyor replace a peer surveyor during the survey? 
    No. Currently, patient surveyors are an additional surveyor on the survey team.  
  5. How are patient surveyors trained to become an Accreditation Canada surveyor?
    Patient surveyors undergo the same screening and selection process as peer surveyors, which includes completing an interview and reference check, completing in-person surveyor training, participating in an internship survey and completing an orientation exam. Surveyors will be retained if they successfully complete all of these selection components. All surveyors are required to complete annual certification requirements to ensure their competencies remain current, and they are knowledgeable on updates to the program.
  6. Can organizations request patient surveyors who have certain skills or perspectives? For example, can we request a patient surveyor with experience in a pediatric setting?
    As with all surveyors, every effort is made to match the surveyor’s background and experience with those delivered by the organization. As indicated on the webinar, the core function of a patient surveyor is not to provide recommendations based on their own personal experience, but rather, to reveal and deepen understanding of the experience of the clients and client advisors of the organization. 
  7. Will client organizations have the opportunity to review the patient surveyor profiles prior to the survey?
    Yes. Organizations have the opportunity to review both peer and patient surveyor profiles prior to the survey visit on the client portal.  
  8. How does Accreditation Canada ensure patient surveyors remain unbiased during an accreditation visit?
    Patient surveyors, like all Accreditation Canada surveyors, are required to follow Accreditation Canada’s conflict of interest policy. This ensures that surveyors declare any potential conflict of interest they may have with any of Accreditation Canada’s client organizations. As such, a patient surveyor would never survey in an organization where they have been a patient. All surveyors are also provided with education on cognitive biases, how to remain objective, and avoid forms of bias that could influence survey results. 
  9. How is Accreditation Canada evaluating the inclusion of patient surveyors on accreditation surveys? 
    As part of our ongoing process improvement, feedback on the patient surveyor experience is captured through client questionnaires. In addition, each patient surveyor is interviewed following an accreditation survey to capture what went well and what can be improved. Adjustments are made on a continuous basis to ensure a positive experience for all. In addition, our Patient Partnerships team monitors and evaluates the experience of staff, leaders and all patient partners collaborating on standards development and assessments. The team uses this feedback to inform reflective learning exercises and continuous quality improvement processes.  
  10. Someone from my organization is interested in becoming a patient surveyor. How do they apply? 
    Information on how to become a surveyor as well as current opportunities are available on Accreditation Canada’s website: 


Technical Questions 

  1. Why was the decision made to hold the rollout of the new IT platform?
    In May 2018, we provided advanced access to part of the IT platform (i.e. [pro]gress) to a select group of clients. Since that launch, we received feedback from early users reporting significant functional issues with the platform. To ensure we are responsive to this valuable feedback, we have suspended the use of the platform until further notice.  
  2.  When will the new IT platform be ready?
    A new cross-functional team has been established and is committed to continuing development activities related to the new IT platform. Updates on these development activities will be disseminated to clients through this landing page and in upcoming communications.  
  3. I was unable to connect to one of your webinars due to the firewall in my organization. What can I do?
    Some organizations have stringent firewalls in place that may prevent access to webinars. For Program Update webinars, a recording will be posted to the landing page so that you can access the recording following the event.