The Launch of Accreditation 2010: Phase one: self-assessment

MUHC accreditation starts soon.

In anticipation of Accreditation Canada’s visit in September 2010, the first phase of the process called “self-assessment” will take place from the beginning of April until the end of September 2009. Compared to the last accreditation visit in 2007, several changes have been made to the process. Under the theme “Working Together”, Accreditation Canada’s new program QMENTUM aims for a wider participation of the MUHC members in continuous quality improvement. The self-assessment phase relies on the participation of staff and doctors by inviting them to complete a series of surveys that assess our conformity to Canadian standards.

Your contribution is at the heart of the Accreditation process’ success.
Here, in brief, are the highlights of the phase one of the 2010 accreditation process: self-assessment:



1. What is QMENTUM?
Qmentum is a program from Accreditation Canada that ensures quality improvement activities are part of the day-to-day activities of the MUHC.

2. What does QMENTUM consist of?
The four phases of the Qmentum process are Self-assessment, Roadmaps, Preparation for Tracers, and the Accreditation Visit. Required Organizational Practices (ROPs) are an integral part of all four phases.

3. What are Required Organizational Practices (ROPs)?
ROPs are essential practices that minimize risk and improve patient safety. Examples of ROPs include medication reconciliation, reporting and disclosure of incidents/accidents, and staff education on hand hygiene or the prevention of falls.

4. How do staff and doctors participate in QMENTUM?
In the first phase, Self-assessment, many of you will be asked to complete one or more questionnaires. Staff will be given the questionnaire that best suits their work responsibilities.

5. How much time does completing a QMENTUM questionnaire take?
Depending on the questionnaire, it will take between 15 minutes and an hour. A guide will be available to help you understand the questions.

6. If I work in more than one service, how should I respond?
You should answer based on the service in which you spend most of your time.

7. I’m not very computer-savvy. I don’t even have a computer in my office. How can I fill out the questionnaire?
Every effort will be made to simplify the process. A guide will be available and you will have a list of contact people who can help. In some areas, you may have the choice of completing the questionnaire on paper instead of on a computer.

8.  What happens to the QMENTUM questionnaires once completed?
Each MUHC team will quickly receive results of the questionnaires in the form of a Roadmap, highlighted with red, yellow or green flags. The red and yellow flags identify areas that need improvement. Each team will decide where to focus its improvement efforts, create an action plan, and begin to make changes as necessary. We will have at least six months to work on these improvement plans.

Evidence of the actions we’ve taken to improve quality must be sent to Accreditation Canada by June 2010, in preparation for the Accreditation Visit in September 2010.

9. What happens during the Accreditation Visit?
During the Visit, the surveyors will use the Tracer method to gather information. This means they will tour all over the MUHC hospitals, talking to many different staff, reviewing documents, and observing a variety of activities to evaluate quality of care.
Our goal is to make quality improvement a part of the MUHC’s day-to-day operations and culture.

The Qmentum Self-assessments, Roadmaps, Tracers and Visit will help us do just that, by asking all of you to participate. Share your ideas, help put your ideas into practice, and contribute to better patient care!