Required Organizational Practices (ROP) Handbook 2017 - Version 2

Required Organizational Practices (ROP) Handbook 2017 - Version 2For convenience and ease of use, all of the Required Organizational Practices in the Accreditation Canada Qmentum program have been collected into this handbook. Supporting evidence used to develop the ROP (which is not included in the Qmentum standards), as well as tools and resources to assist organizations in meeting the tests are included.

The ROPs, categorized into six patient safety areas, are:

Safety Culture

  • Accountability for quality
  • Patient safety incident disclosure
  • Patient safety incident management
  • Patient safety quarterly reports


  • Client identification
  • The ‘Do Not Use List’ of abbreviations
  • Information transfer at care transitions
  • Medication reconciliation as a strategic priority
  • Medication reconciliation at care transitions
  • Safe surgery checklist

Medication Use

  • Antimicrobial stewardship
  • Concentrated electrolytes
  • Heparin safety
  • High-alert medications
  • Infusion pump safety
  • Narcotics safety


  • Client flow
  • Patient safety: education and training
  • Patient safety plan
  • Preventive maintenance program
  • Workplace violence prevention

Infection Control

  • Hand-hygiene compliance
  • Hand-hygiene education and training
  • Infection rates
  • Reprocessing

Risk Assessment

  • Falls prevention
  • Home safety risk assessment
  • Pressure ulcer prevention
  • Skin and wound care
  • Suicide prevention
  • Venous thromboembolism prophylaxis

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The ROP Handbook is available for purchase in the Accreditation Canada E-Store.

Current clients – contact your Accreditation Specialist to obtain the ROP Handbook.

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