Accreditation 2020

Accreditation 2020

Manitoba Renal Program is part of an Accreditation process happening at Winnipeg sites starting this November.

UPDATE: Due to COVID-19 the Accreditation process will now happen in two phases. Phase one will be virtual and involve primarily administrative staff. Phase two will be in-person and occur in the spring (date to be determined.) 

Phase one virtual interviews will take place between November 22nd to 27th, 2020. 

Printables for Staff Areas:

Accreditation Posters 1 – 6

QIP Overview Poster

Accreditation FAQ

Accreditation Canada provides a set of standards of care for health facilities across Canada. All Winnipeg renal/dialysis units are being reviewed to see how well they are achieving these.

There are many different standards that all hospitals are assessed on. Renal programs in Winnipeg are being assessed on Ambulatory Care Services Standards with several keys areas of focus. You can read more about these in detail here but there is also information below.

Surveyors may be in your workplace and/or ask you about practices and policies at your site and in your unit. Surveyors use the Tracer method to evaluate both clinical (direct care) and administrative processes. You can learn more about the tracer method here. Surveyors are not evaluating individual staff or treatment paths — they are looking to understand the processes we use to deliver services. 

Surveyors will provide a report that summarizes how we are, or are not, meeting the standards MRP is being assessed on. Our program can use that information to improve our patient care and processes.

Last year, staff participation in Self Assessment Questionnaires (SAQs) helped identify what standards of care renal staff think we can improve on.

Using the SAQ results, MRP developed a Quality Improvement Plan. Hospitals and their respective renal programs have also developed their own relevant quality initiatives.

Accreditation: Accreditation means to certify as meeting a specific set of national standards of excellence. The WRHA follows standards established by Accreditation Canada. The Regional Health Act requires all health authorities to be accredited and maintain accredited status.

Qmentum: Qmentum is the name of the accreditation process used by Accreditation Canada. It combines the words “quality” and “momentum” in recognition that this new program helps to align accreditation with the organization’s ongoing quality improvement process. The Qmentum process consists of a self assessment (questionnaire), an onsite survey and follow-up actions for improvement.

Standards of Excellence: Accreditation Canada has established sets of standards for many areas of service provision and practice within healthcare. The MRP is being evaluated using the Ambulatory Care Services standard.

Required Organizational Practices (ROPs): An ROP is a necessary practice that organizations must have in place to enhance patient/client safety and minimize risk. Ambulatory Care Services has four ROPs that we must address. Detailed information about these ROPs will be provided in upcoming updates.

Surveyors: Surveyors, or accreditors, are peer reviewers. They hold leadership positions in healthcare in other provinces across Canada and are trained by Accreditation Canada to conduct site visits in their areas of expertise.

Priority Process: A key process within the organization that reflects critical areas and systems that are known to have significant impact on the quality and safety of care and services. Accreditation Canada has identified 22 priority processes

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

To see the full ROP handbook click here.

More Accreditation information from WRHA can be found here.

MRP is being assessed on how well and thoroughly we are implementing different standards.

Leading up to November’s Accreditation process, we are highlighting ways we meet some of the standards you may be asked about at your site:

(Please note your site may have additional ways it meets these criteria – these can be highlighted during staff huddles/meetings using the practice questions)


Using 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

  • How do you know who you are caring for?
  • How do you check the identity of patients before providing treatment or medication?
  • How do you identify your patient over the phone?
  • Before you start a procedure, how do you identify that you have the correct patient?
  • Can you tell me how you identify a patient that is not able to identify themselves?
  • What patient identifiers do you request from the patient?
  • Before you start a procedure, how do you identify that you have the correct patient?
  • Can you tell me how you identify a patient that is not able to identify themselves?
  • What patient identifiers do you request from the patient?
  • All dialysis patients have photos in their charts
  • Staff confirm addressograph information with chart information and visual identification of patient
  • In person: Identifiers include client’s full name, date of birth, an accurate photograph, facial recognition or home address (confirmed by Client or family)
  • Over the phone: Patient confirms full name, date of birth and/or Manitoba health card number.
  • MRP guidelines for patient identification 80.10.01

Information Transfer at Care Transitions

Information relevant to the care of the client is communicated effectively during care transitions.

  • When do you need to provide patient information?
  • How do you provide information to the next provider of care?
  • How does the multidisciplinary team facilitate communication with other client services?
  • How is information communicated to the inter-professional team?
  • What information do you provide at patient hand off during breaks or at end of shift?
  • What tools or processes do you use when relaying patient information?
  • How are patients informed about transitions in their care?
  • How are patients involved in their care?
  • Tell me how you receive information about a new patient in your unit? (i.e. new clinic patient, starting PD, PDCC, HHD etc.)
  • How is patient information communicated to you?
  • Give me an example of the patient information you communicate to coworkers when you leave the unit for break? 
  • Describe how information is exchanged with allied health (social work. pharmacy, OT, dietitians)?
  • How is information shared with family physicians?

Transferring between units:

Nurse Transitions:

  • MRP policies on transfer of patient information during nursing transitions (80.10.03)
  • Hemodialysis RNs and LPNs are responsible for assessing, documenting and verbally reporting on specific patient clinical data when transferring a patient to another provider
  • Nurse-to-nurse report cue cards with key points for rounds and care hand offs
  • Guidelines for communications for managing hospitalized patients (80.20.05)
  • Guideline for a communication record between MRP and Long Term Care (LTC) (60.20.06)
  • Other tools used include SBAR, Team STEPPS & SHOT

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.

  • What is the process you follow when a medication is ordered?
  • What kinds of medication errors get reported?
  • How do care providers reconcile medications upon admission?
  • How does information about the client’s medication get communicated to the next provider of service?
  • What do you do if a medication order is incomplete or illegible?
  • How do you check the identity of patients before administering medication, collecting or administering blood or performing other procedures or treatment?
  • How are medication changes communicated to patients?
  • What is a best possible medication history (BPMH)?
  • How are medication discrepancies resolved?
  • What processes do you have in place for MedRec in your area of care?
  • Does your area of care have a standardized MedRec policy for staff members to follow?
  • How do you know which ambulatory care clinics are responsible to perform MedRec in your organization?
  • What points in care is MedRec to be done in your ambulatory care clinic? 
  • How often is MedRec done for a client being followed by your services? How do you know this?
  • What is done with the BPMH once you have obtained it?
  • What is done if discrepancies between BPMH and current medication orders are identified?         
  • How often/frequently is MedRec completed for your ambulatory care clients?
  • Who is responsible to perform MedRec? Who else is involved in your process? 
  • How is MedRec information communicated to the client? To the next service providers? Where would this information be documented? How do you know this MedRec information is sufficient for the next provider?
  • How do you share MedRec information with clients & families at times of transition?
  • What type of MedRec information do you share with them?
  • Is there a process to determine to what degree the client/family understand the information?
  • MRP policy 80.10.02 outlines the Best Possible Medication History, client groups that require medication reconciliation and what points of care where it’s required.
  • eKHR generates medication flow sheets and medication cards.
  • Pharmacists do medication reconciliation for all dialysis patients when they are new to dialysis, permanently transferred, at home dialysis clinic visits or every 6 – 12 months
  • Patients can contact renal pharmacists
  • Patients get medication change forms (80.10.02a) and medication cards for changes
  • Medication changes communicated to care providers are documented on the PD and Hemodialysis Outpatient Prescription Form
  • The Medication Reconciliation LMS module educates about what a Best Possible Medication History is

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.

  • How do you receive education on infusion pumps?
  • What kinds of infusion pumps are used in your service area?
  • What training do you receive as an employee?
  • How are these training sessions standardized within your site/program?
  • When do staff members have to take these sessions?
  • When did you last receive training?
  • If your patient needs an infusion pump & you haven’t used that type of pump regularly, what do you do?
  • Where are the instruction and user guides for infusion pumps kept?
  • How does your area of care address infusion pump safety?
  • Tell me about your policy, procedure, SOP or guideline or process on infusion pumps.
  • Training during:
    • Job orientation from Site Educators
    • Equipment updates
    • Bi-annual quiz
  • Educators monitor staff participation and evaluate/implement changes as needed
  • Training manuals are available on hospital websites
  • Dialysis Technologists maintain infusion pumps

Fall Prevention

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.

  • How do you assess your patients for falls?
  • How do you educate your patient on falls prevention?
  • What happens if a patient falls during an appointment – what steps are taken afterward?
  • What tools or education have you used or taken?
  • What resources on fall prevention are available for patients?
  • What is your role in falls prevention?
  • How does your area of care address falls prevention? 
  • Tell me about your organization’s policy, procedure, SOP or guideline for falls prevention /injury reduction
  • What are universal precautions?
  • What universal precautions do you use?
  • Are they standardized within your program?
  • Tell me about any additional strategies/interventions you may use. When do you use these?
  • How do you communicate the details of a patients falls risk /interventions in place, at times of transition?
  • Where do you document falls prevention information / interventions?
  • Renal staff use the Community and Ambulatory Care Client Falls Risk Screening Tool to screen in-center hemodialysis, renal health clinic, peritoneal dialysis and home hemodialysis patients
  • In-centre hemodialysis patients screened as high risk for falls are additionally assessed with the Falls Risk Assessment Tool (Schmid)
  • Sites implemented the Universal Falls Precautions (SAFE) processes at their sites with poster reminders in the units
  • Clients are educated and provided with “Staying on Your Feet” resources as required.
  • LMS education module Fall Prevention is available for staff

Quality Improvement Plans

Please also take a look at our MRP Quality Improvement Plan Overview for more information.