Dr. Steven Soroka is the senior medical director, Renal Program and Pharmacy Services at Nova Scotia Health. He is also a surveyor with Accreditation Canada, a not-for-profit, independent organization that provides national and international health care organizations with an external peer-review process.
Since 2008, Dr. Soroka has surveyed health care facilities/hospitals in Canada, North America and as far away as Saudi Arabia. He was also the chair of the physician advisory committee of Accreditation Canada. During this process, organizations are reviewed against a set of standards of excellence and required organizational practices (ROPs) and if criteria is met, they received an Accreditation status.
As Nova Scotia Health prepares for its upcoming Accreditation survey in October 2022, Dr. Soroka offers advice to teams and individuals across Nova Scotia Health.
As a surveyor, what would you say are the most important things you look for?
What I want and look to see is that there's been a commitment to quality and safety. We rate against standards and required organizational practices (ROPs) and we want to see them in action.
For me, and most surveyors, it’s nice to see the written policy, but at the patient care level we want to see if people are actioning these policies and procedures. As a surveyor I am looking for evidence. This could be collected by looking at patient charts, seeing audits or results of audits on quality boards on a unit, and talking to front line staff and patients.
When talking to staff and patients, I want to get an understanding that they’re committed to quality and safety. For example, I may ask patients if they were satisfied with the care they received. If not, were they informed who they should contact. Another conversation may include asking a staff member about the type of training they completed to be able to do their job. This may be initial orientation or training on a new piece of equipment or a new policy.
What would you say to people who are nervous or fearful of Accreditation?
Sometimes when I do mock tracing (a simulation of the onsite survey experience) I get asked what the right answer is. I always say there isn’t a right answer if you are telling me what you do. If you’ve been trained as a health professional, you're doing what you would do and if you're following standard operating procedure(s), then you're doing the right thing.
You should never feel like surveyors are asking a trick question. If you don't understand the question, feel free to ask the surveyor to clarify what they're looking for.
For teams within Nova Scotia Health, what's the best way they can prepare for the accreditation survey?
Know your standards. There are system-based and service-wide standards. Within the standards there are ROPs and high priority criteria. You have to be conscious of them and be prepared to answer questions around them.
The other important thing is look at the report from the last survey that was done. If there are any unmet criterion, look at the standards and find out what is required to meet the standard, as most surveyors will go back to the previous survey report when preparing for the current survey.
Any last words of wisdom?
As health care providers, we strive for continuous learning, always trying to be better, and incorporate new evidence and knowledge for incremental improvements. These improvements demonstrate the commitment of the organization, and all the people that work within it, to increase quality and safety for patients, their families and each other.
Visit the Accreditation intranet for more information and resources
Physicians can visit the Nova Scotia Health Accreditation page on the Physicians portal.