Quality & Accreditation

Accreditation 2020 – Renal Programs in Winnipeg


February 11, 2020:

October 22, 2019:

  • Site visits are POSTPONED and will not take place until fall 2020.
  • All WRHA staff have been asked to participate in a new SAQ (questionnaire) on Indigenous people as a priority population for the Population Health and Wellness Standard. You will have received an email with a link and password on Monday, October 21. The SAQ closes on November 4th.

Update September 13, 2019:

  • AC surveyor site visits are scheduled for April 26 – May 1, 2020.

Upcoming workshops:

Update May 13, 2019: MRP Winnipeg sites have been asked to participate in an Infection, Prevention & Control SAQ.

Update March 27, 2019: A link to a Self Assessment Questionnaire (SAQ) will be sent out to staff starting April 1, 2019


Step 1: 2017-2019

Step 2: April – May, 2019

Step 3: May 2019 – March 2020 (& ongoing implementation of improvement plans)

Step 4: April 26 – May 1 2020

How does this affect you as a renal health-care provider in Winnipeg?

  • You will be asked to do an online questionnaire
  • We will be sharing relevant information with you throughout the process
  • You may be asked questions when an Accreditation Canada Surveyor does a site visit to review our program

What are renal programs in Winnipeg being asked about and measured on?

MRP is being assessed on four identified Required Organization Practices (ROPs) which include specific tests for compliance. They are:

  • Infusion pump safety: A documented and coordinated approach for infusion pump safety that includes training, evaluation of competence, and a process to report problems with infusion pump use is implemented.
  • Medication reconciliation: Medication reconciliation is conducted in partnership with clients and families to communicate accurate and complete information at ambulatory care visits when medication management is a major component of care.
  • Use of two Client identifiers: Working in partnership with clients and families, at least two person-specific identifiers are used to confirm that clients receive the service or procedure intended for them.
  • Information transfer at care transitions: Information relevant to the care of the client is communicated effectively during care transitions.

To see the full ROP handbook click here.

Renal programs in Winnipeg are also being assessed on Ambulatory Care Services Standards High Priority Criteria Areas. These include:

1.1 Services are co-designed with clients and families, partners, and the community.

3.1 Required training and education are defined for all team members with input from clients and families.

3.2 Credentials, qualifications, and competencies are verified, documented, and up-to-date.

3.7 Education and training are provided on the safe use of equipment, devices, and supplies used in service delivery.

3.10 Team member performance is regularly evaluated and documented in an objective, interactive, and constructive way.

3.12 Team members are supported by team leaders to follow up on issues and opportunities for growth identified through performance evaluations.

4.1 A collaborative approach is used to deliver services.

4.4 Standardized communication tools are used to share information about a client’s care within and between teams.

5.5 Education and training on occupational health and safety regulations and organizational policies on workplace safety are provided to team members.

5.6 Education and training are provided on how to identify, reduce, and manage risks to client and team safety.

5.7 Education and training are provided to team members on how to prevent and manage workplace violence, including abuse, aggression, threats, and assaults.

 5.8 The organization’s policy on reporting workplace violence is followed by team members.

7.9 The client’s informed consent is obtained and documented before providing services.

7.10 When clients are incapable of giving informed consent, consent is obtained from a substitute decision maker.

7.12 Ethics-related issues are proactively identified, managed, and addressed.

7.13 Clients and families are provided with information about their rights and responsibilities.

7.14 Clients and families are provided with information about how to file a complaint or report violations of their rights.

7.15 A process to investigate and respond to claims that clients’ rights have been violated is developed and implemented with input from clients and families.

8.1 Each client’s physical and psychosocial health is assessed and documented using a holistic approach, in partnership with the client and family.

8.6 Universal fall precautions, applicable to the setting, are identified and implemented to ensure a safe environment that prevents falls and reduces the risk of injuries from falling.

8.10 A comprehensive and individualized care plan is developed and documented in partnership with the client and family.

9.4 Treatment protocols are consistently followed to provide the same standard of care in all settings to all clients.

9.5 The client’s health status is reassessed in partnership with the client, and updates are documented in the client record, particularly when there is a change in health status.

9.11 Specific processes are used for transferring information when clients do not have a regular health care provider.

10.1 Clients and families are actively engaged in planning and preparing for transitions in care.

11.1 An accurate, up-to-date, and complete record is maintained for each client, in partnership with the client and family.

11.3 Policies and procedures to securely collect, document, access, and use client information are followed.

11.6 Policies and procedures for securely storing, retaining, and destroying client records are followed.

11.8 There is a process to monitor and evaluate record-keeping practices, designed with input from clients and families, and the information is used to make improvements.

13.1 There is a standardized procedure to select evidence-informed guidelines that are appropriate for the services offered.

13.3 There is a standardized process, developed with input from clients and families, to decide among conflicting evidence-informed guidelines.

13.4 Protocols and procedures for reducing unnecessary variation in service delivery are developed, with input from clients and families.

13.5 Guidelines and protocols are regularly reviewed, with input from clients and families.

13.6 There is a policy on ethical research practices that outlines when to seek approval, developed with input from clients and families.

14.1 A proactive, predictive approach is used to identify risks to client and team safety, with input from clients and families.

14.2 Strategies are developed and implemented to address identified safety risks, with input from clients and families.

14.3 Verification processes are used to mitigate high-risk activities, with input from clients and families.

14.6 Safety improvement strategies are evaluated with input from clients and families.

14.7 Patient safety incidents are reported according to the organization’s policy and documented in the client and the organization record as applicable.

14.8 Patient safety incidents are disclosed to the affected clients and families according to the organization’s policy, and support is facilitated if necessary.

14.9 Patient safety incidents are analyzed to help prevent recurrence and make improvements, with input from clients and families.

15.3 Measurable objectives with specific time frames for completion are identified for quality improvement initiatives, with input from clients and families.

15.5 Quality improvement activities are designed and tested to meet objectives.

15.8 Indicator data is regularly analyzed to determine the effectiveness of the quality improvement activities.

15.9 Quality improvement activities that were shown to be effective in the testing phase are implemented broadly throughout the organization.

To see all these Ambulatory Care Services Standards in detail click here.

More Accreditation information from WRHA can be found here.

Looking Back –  Accreditation 2016

Cultural competency/safety

  • Since then:
    • WRHA implemented MB Indigenous Cultural Safety Training available to all staff
    • Promoted WRHA Indigenous Health workshops (also linked on our website here)
    • Support learning opportunities such as Orange Shirt Day and WRHA Indigenous Health Grand Rounds
    • Reminders to staff about the Aboriginal Liaison Coordinator position and services provided by Indigenous Health

Managing ethical/moral dilemmas

Orientation process for physicians on workplace policies and safety

Evaluation of education and information provided to clients/patients

  • Since then:
    • PD patient and staff survey (2017)
    • Utilize site patient satisfaction survey results (last survey done in 2014)

Continued implementation of Falls Prevention Strategy

  • Since then:
    • PD Falls Prevention post clinic chart audit at St. Boniface (2018)
  • Extremely engaged staff
  • Strong clinical leadership
  • Interdisciplinary team model dedicated to meet the needs of our patients
  • Strong staff orientation and training for new staff, students and volunteers
  • Client satisfaction reflected during patient in-person interviews
  • Provide client centered care
  • Flexibility to accommodate client requests where possible, to facilitate access
  • Providing clients and families with information pertinent to their specific needs
  • Client information provided in easy to understand language
  • Interpretive services are readily available if required
  • Strong understanding of the safety, benefits and implementation of MedRec
  • Evidence of reducing variation and improving clinical standardization
  • Specific goals and clear targets evident in our Quality improvement roadmap and displayed on Quality boards
  • Dedicated research and development to support improvements to client care and care environments

2017-19 Quality Roadmap

Latest News

February 13, 2020 | News Staff News

A new, near real-time data platform for Manitoba’s health-care system was announced Thursday, February 13. The project received funding support…

Read Full Story

January 23, 2020 | News Patient News Staff News

Several Manitoba dialysis units are expanding their capacity this year.

Read Full Story

January 16, 2020 | News Recipes

A kidney-friendly take on this classic recipe.

Read Full Story