It’s Accreditation Time

Working Together for Better Quality and Safety in Health Care Delivery

Thunder Bay Regional Health Sciences Centre (TBRHSC) is taking part in Accreditation Canada’s Qmentum accreditation program, which will culminate with an on-site survey scheduled for May 2022.

Accreditation is a continuous quality improvement process; it helps our organization identify what we are doing well and where we need to focus our improvement efforts. Everyone in our organization plays a vital role in accreditation, including professional staff, front-line staff, non-clinical employees, volunteers, Board members, patients, and families.

Health care accreditation through the Qmentum program is an ongoing process of assessing health care organizations against standards of excellence to identify what is being done well and what needs to be improved. It is a four year cycle with completion of key requirements leading up to the on-site survey.

In 2018, TBRHSC passed Accreditation with Commendation. The Accreditation decision guidance is as follows:

Even though we attained 98.4% for Total Criteria, we had a few Required Organization Processes that were unmet. These were followed up in subsequent interactions with Accreditation Canada.

Quality and Risk Management is the corporate lead for Accreditation. Following engagement with leaders, we have rolled out the assessments for standards. We encourage everyone to participate in their program and department assessments.

Accreditation Canada solicits the experience of staff through the Worklife Pulse and the Canadian Patent Safety Tools. These are 2-page individual response surveys collated through the Accreditation portal. Based on the employee number and the response rate of 2018, we are required to attain the following threshold:

Share your experience by completing a survey before April 30th

To complete a survey and ensure proper data collection, please use the survey link below that most accurately reflects your role and area of care. The survey takes approximately 5-10 minutes to complete. There is the option to resume the survey if you wish to complete it in multiple sittings. Copy the ‘Resume Code’ as indicated on the bottom tab. For the best experience, please access the survey by opening the link with your Chrome browser. All inputs are anonymized and aggregate results will be provided after the closing date of April 30th, 2021.


Worklife Pulse (all staff: clinical and non-clinical)

Worklife Pulse for Physicians (specific to physicians)

Canadian Patient Safety Culture Survey Tool (all front-line staff and administrative staff working in clinical units/areas)

All updates will be shared with staff as we complete our milestones: assessments, survey tools, patient experience results, training and dry runs for departments and programs.

For more information about accreditation, please contact Chitra Jacob, Manager, Quality and Risk Management at jacobc@tbh.net.

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