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Nova Scotia Health Accreditation

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The Accreditation on-site survey involves measuring our organization against world class evidence-based standards that focus on quality of care and patient safety to determine where we’re doing well and where we need to make improvements. During the week of October 16 to 21, 2022, surveyors from Accreditation Canada will visit sites across all four zones and speak with a variety of people within Nova Scotia Health. They will also make observations and review documentation to evaluate if the organization is in alignment with evidence-based criteria. 

It is a complementary process that validates a variety of daily activities already occurring to improve outcomes and experiences for those we serve.

Physician participation is critical for patient safety and to meet accreditation requirements. Please review the Physician Responsibilities with Accreditation Required Organizational Practices (ROPs) to ensure you are aware and follow these ROPs.

Watch the Accreditation 101 video to learn about the upcoming on-site survey and how you can prepare: 

Below are the physician-related resources to help you prepare for Accreditation: 

Resources
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Physician Involvement in Meeting the Accreditation Required Organizational Practices (ROPs)

Physician participation is critical for patient safety and to meet accreditation requirements. Please review this document to ensure you are aware and follow these ROPs. 

Tags:
Accreditation / ROPs
Last Updated:
December 7, 2023
1
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Required Organizational Practices 2020 Handbook

All of the Required Organizational Practices in the Accreditation Canada Qmentum program have been collected into this handbook. Most apply to more than one health sector or service and therefore appear in multiple sets of standards. The applicable standards sets are identified at the beginning of the ROP or in the table at the end of the handbook.

Tags:
Accreditation / ROPs
Last Updated:
December 7, 2023
1
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Quality Improvement and Safety Clinical Orientation

 This resource covers quality, risk, and safety in healthcare. 

Tags:
Accreditation / ROPs
Last Updated:
December 7, 2023
1
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Patient Safety Incident Management (ROP)

In a culture of patient safety, everyone is encouraged to report and learn from patient safety incident. A reporting system facilitates monitoring and learning from data to prevent recurrences.

Tags:
Accreditation / ROPs
Last Updated:
December 7, 2023
1
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Patient Safety Incident Disclosure (ROP)

Research shows a positive relationship between patient satisfaction with how a patient safety incident is handled by an organization and formal open disclosure. Disclosing in an open and timely manner may maintain the patient’s positive relations with service providers and reduce risk of litigation. Disclosure is required for all patient safety incidents which reach the patient (including where there has been no harm).

Tags:
Accreditation / ROPs
Last Updated:
December 7, 2023
1
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Hand Hygiene Education + Training One Pager (ROP)

Hand hygiene is considered the single most important way to reduce health care-associated infections. Cost estimates of health care-associated infections significantly exceed those related to hand hygiene.

Tags:
Accreditation / ROPs
Last Updated:
December 7, 2023
1
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Patient/Client Identification (ROP)

Using two patient identifiers to confirm that patients receive the service or procedure intended for them can avoid patient safety incidents (e.g., medication errors).

Tags:
Accreditation / ROPs
Last Updated:
December 7, 2023
1
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Information transfer at care transitions (ROP)

Information transfer has been identified as critical in improving patient safety, particularly at transition points - ensuring the accurate and timely exchange of information to minimize misunderstanding.

Tags:
Accreditation / ROPs
Last Updated:
December 7, 2023
1
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Medication Reconciliation at care transitions (ROP)

Research suggests that over 50% of patients have at least one discrepancy between the medications they take at home with those ordered upon admission to the hospital. Many of these have the potential to cause medication related patient safety incidents.

Tags:
Accreditation / ROPs
Last Updated:
December 7, 2023
1
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“Do not Use” List of Dangerous Abbreviations (ROP)

An average of 5% of medication errors are attributable to dangerous abbreviation use. Medication errors can lead to an increase in the length of stay, more diagnostic tests and changes in drug treatment.

Tags:
Accreditation / ROPs
Last Updated:
December 7, 2023
1
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Safe surgery checklist (ROP)

Safe surgery checklists play an important role in improving the safety of surgical procedures (e.g., wrong surgery, retained objects) as they can reduce the likelihood of complications following surgery and improve surgical outcomes.

Tags:
Accreditation / ROPs
Last Updated:
December 7, 2023
1
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Venous thromboembolism (VTE) prophylaxis (ROP)

Development of VTE is the most common preventable cause of hospital death. Incidence of VTE can be reduced or prevented by identifying patients at risk and providing appropriate, evidence-informed thromboprophylaxis.

Tags:
Accreditation / ROPs
Last Updated:
December 7, 2023
1
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Antimicrobial Stewardship (AMS) (ROP)

Antimicrobial stewardship programs optimize the use of antimicrobials to improve patient outcomes, reduce the risk of infections including Clostridium difficile, reduce or stabilize levels of antibiotic resistance, decrease drug toxicities, and promote patient safety.

Tags:
Accreditation / ROPs
Last Updated:
December 7, 2023
1
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Client Flow (ROP)

Overcrowding is a system-wide challenge and usually a result of a mismatch between capacity and demand. Evaluating client flow data facilitates development of strategies to meet variations, reduce barriers, and prevent overcrowding.

Tags:
Accreditation / ROPs
Last Updated:
December 7, 2023
1
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Annual patient safety education & training (ROP)

Educating health care providers about patient safety and enabling them to use this knowledge to build and maintain a safe system is critical to creating the safest health system.

Tags:
Accreditation / ROPs
Last Updated:
December 7, 2023
1
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Infection Rate (ROP)

Physicians who are well informed about infection rates are better equipped to prevent and manage infection rates. Use of infection rates may focus on a particular health care-associated infection, or may be service, program or organization wide.

Tags:
Accreditation / ROPs
Last Updated:
December 7, 2023
1
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Policy Wayfinding for Policy Users

How to find your policies and procedures on Nova Scotia Health’s Policy Portal (aka OP3).

Tags:
OP3 / Accreditation / ROPs
Last Updated:
December 7, 2023
1
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Accreditation Standards - System Wide Standards

Tags:
Accreditation
Last Updated:
December 7, 2023
6
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Accreditation Standards - Service Based Standards (PDF)

Last Updated:
December 7, 2023
28
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Contact

Nancy McLaughlin
NS Health Accreditation Lead
Nancy.McLaughlin@nshealth.ca

Contact

Amanda Creelman
Manager, Accreditation
Amanda.Creelman@nshealth.ca

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