Healthcare Quarterly

Healthcare Quarterly 7(4) September 2004 : 44-48.doi:10.12927/hcq..16813
Ideas at Work

Aim for Excellence: Integrating Accreditation Standards into the Continuous Quality Improvement Framework

Wendy L. Nicklin, Tena McLellan and James A. Robblee


[No abstract available for this article.]
"Accreditation is a process that organizations use to evaluate their services and to better the quality of their services. Accreditation also provides recognition that an organization's services are meeting national standards of quality." - Canadian Council on Health Services Accreditation, 2004


Hospitals and other healthcare organizations take part in a periodic review by the Canadian Council on Health Services Accreditation (CCHSA). In order to participate in the accreditation process, organizations undergo extensive preparation. This includes an orientation and a review of the standards and an evaluation process by the leadership team, clinical teams and support teams, followed by rigorous preparation for the site visit and accreditation surveyor interviews. In the period between surveys, organizations implement any recommendations included in their final accreditation report. In addition, many organizations endeavour to incorporate the CCHSA standards into ongoing operations, service delivery, new program development and continuous quality improvement programs. The purpose of this article is to introduce a process that will facilitate the use of the CCHSA standards by clinical teams between accreditation site surveys.

The Ottawa Hospital (TOH) has developed a simple template incorporating specific key CCHSA criteria that will allow clinical teams to annually self-assess their activities against the accreditation standards. The results of this exercise will form their quality improvement plan for the next year. It is anticipated that the process will ensure that accreditation becomes a threeyear continuous cycle. When standards are applied in a regular ongoing fashion, their value as part of the hospital's quality improvement program can be realized. In addition, the volume of work required to prepare for site surveys can be decreased through an iterative process of standards self-assessment.


The Ottawa Hospital (TOH) is a multi-sited academic health science centre formed under the direction of the Health Service Restructuring Commission in 1998. The subsidiary organizations, the University of Ottawa Heart Institute (UOHI) and the Rehabilitation Centre (TRC), participate in an integrative process for hospital accreditation. Together, these organizations provide tertiary and quaternary health services and the majority of primary and secondary adult programs to patients in Ottawa and Eastern Ontario. TOH, UOHI and TRC are affiliated with the University of Ottawa and with two research institutes, the Ottawa Health Research Institute and the Heart Institute Research Corporation.

TOH developed a new quality improvement (QI) framework in 2003. This framework enables a coordinated system for QI in the hospital and identifies the structures, the processes, the accountabilities and the improvement methodology. The framework enables the implementation of the hospital's annual QI plan, and provides a number of tools for measuring, evaluating and improving quality. It includes the accreditation process as one evaluation component of the Quality Program for the hospital.

Literature Review

A commitment to quality coupled with the development and application of standards are fundamental to providing quality healthcare. Standards and criteria are the "vehicles by which the general concepts and attributes of quality … are translated to actual measurements." Criteria for quality "should correspond as faithfully as possible to the concepts of quality that they are intended to measure." Criteria and standards should be stated so that they can be easily understood and accurately measured (Donabedian 2003).

CCHSA has a well-developed standards creation and revision process that involves consulting with healthcare professionals, academics, consumers and other experts from across the country. The standards therefore have a normative derivation. This development process ensures the standards are relevant, appropriate and useful to assess quality across all areas of healthcare organizations. The national scope of the CCHSA and a common evaluation process known as Achieving Improved Measurement (AIM) accreditation enables a level of consistency of service delivery across the country and an opportunity to compare institutional processes with peer organizations.

The CCHSA standards are expressed as a goal to be reached. For each standard, there are criteria. The criteria are the activities that lead to achievement of the standard (Canadian Council on Health Services Accreditation 2004). A number of subsections have been developed in the AIM accreditation program to describe the activities of a healthcare organization. For example, in the Acute Care Standards, one subsection is titled "Being a Learning Organization." This subsection covers such topics as planning services to meet the needs of the population served, research and quality improvement.

It is well recognized that application of the principles of accreditation on an ongoing basis facilitates continuous quality improvement and, through increasing familiarity and relevance of these standards, reduces the workload of an accreditation survey. "Supporting behaviours on a daily basis that support excellent standards of care is more efficient than ramping up for Joint Commission, and also better for the patients and families"(Dukes 2002). The Joint Commission on Accreditation of Healthcare Organizations has recently implemented a new survey process that requires an 18-month self-assessment in which the organization submits a report of areas of noncompliance and details of corrective actions (Dukes 2002). Unfortunately, there is limited information in the literature about frameworks that complement the periodic accreditation process. Specifically, there are no articles relating to the ongoing evaluation of accreditation standards or criteria between surveys. Wagner et al. (1999) studied the use of a structured questionnaire that could be used across different organizations to assess quality assurance processes. Although its purpose was to provide an efficient approach that would complement accreditation reviews, the tool was focused at the organizational level and not at the team level.


Through the authors' involvement with CCHSA and within our own hospital, it is evident that organizations should be challenged to effectively integrate the accreditation standards within their ongoing operations. However, the issue raises several questions:
  1. If the standards were applied on a regular basis as part of program development, implementation and evaluation, could this process form the basis of the organization's quality improvement program?
  2. If team evaluation were carried out more regularly, would less preparation for the formal accreditation site survey be required?
  3. If a mechanism could be developed for teams/programs to self-assess against selected standards on at least an annual basis, would the standards become more integral to the ongoing performance of the organization?
  4. If this process occurred, would it create a more consistent application of standards throughout the organization, resulting in a structured, routine approach to self-assessment and a strengthening of the quality improvement program?

TOH began preparations in late 2002 for the accreditation site survey scheduled for the spring of 2004. The hospital has 32 clinical teams, but only 20 (survey teams) were selected to conduct the self-assessment due to schedule limitations. The teams not involved in the self-assessment process (non-survey teams) were potentially excluded from the benefits of the process, including the development of improvement plans and the opportunity to receive feedback from the accreditation surveyors during the site survey visit. The hospital's Accreditation Steering Committee made a decision to have all teams complete the self-assessment. However, based on feedback from the clinical teams, it was recognized that it was not necessary for the non-survey teams to conduct the same detailed and intensive self-assessment. Consequently, a decision was made to develop an abbreviated self-assessment tool that would complement the accreditation evaluation process.

Our assumption in developing the tool was that the CCHSA standards could be the basis for an effective evaluation framework. This assumption was made because of our commitment to the accreditation process and recognition of the value of the standards for evaluating activities that promote quality in an organization. Rather than address all of the standards it was decided that the tool would focus on key aspects of care addressed by the standards that contribute to quality and are aligned with priority initiatives in the hospital.

Development of the Abbreviated Self-Assessment Tool

For the first phase of the initiative, we selected standards relevant to six key aspects of care: patient safety, patient satisfaction, patient education, clinical ethics, pain management and quality improvement. Each aspect of care was aligned with selected standards and/or criteria (see Figure 1).

[Figure 1]

A focus group of co-leaders of the non-survey teams was convened to review the purpose and content of the tool, to determine if there was support to use the tool and if additional components were required. Refinements to the tool were made based on feedback from the focus group. The non-survey teams were then introduced to the tool and asked to begin using it during their normal team meetings. The specific standard(s) and criteria that align with each aspect have been provided to the teams along with the template. The teams have been asked to identify whether the process is in place or not, provide a description of what is in place and identify strengths and areas for improvement, as well as the plan to address the issues. It is anticipated that the clinical teams will continue to review portions of the framework during regular multidisciplinary team meetings and assess compliance as well as their progress with their plan. The results of this process will be used by the teams to develop their quality improvement plans for the next year.

This self-assessment framework is being integrated into the overall quality improvement framework for the hospital. The intent is that, each year, the areas of emphasis will be reviewed and adjusted if necessary to reflect areas of current importance within the organization or within CCHSA. All teams, including the survey teams, will be encouraged to complete the abbreviated self-assessment annually. As the organization prepares for the next survey expected in 2007, the teams selected for the survey will complete the CCHSA standards and the new "nonsurvey teams" will use the abbreviated tool.

In addition to completing the abbreviated self-assessment, teams are being encouraged to work with other teams on common improvement projects. For example, some teams are working on common discharge teaching and discharge tools to respond to patient satisfaction data that indicated improvements could be made in patient "continuity and transition" processes. Improving these processes is also a corporate priority, so in this way the teams are able to align their efforts with the corporate QI plan. Thus a linkage is established with meeting the accreditation standards and organizational QI.

Benefits of this Approach

The abbreviated self-assessment tool and process, based on the CCHSA standards framework, provides a flexible method to enable teams to focus their evaluation and improvement efforts. Each clinical team uses the same tool to evaluate the same key areas of focus. Quality improvement monitoring and evaluation is tied to explicit accreditation standards using a tool to record results and plans.

Flexibility is a key component of our approach. Priority areas of an organization change, and it is important that the evaluation tool evolve to enable flexibility and relevance to the organization and to the teams. Our intent is to modify the six key aspects of care as necessary. This might entail removing one aspect and adding another once improvements have been made and sustained. For example, if after a year it is evident that the teams are generally meeting a standard area such as the criteria dealing with ethics, then it might be removed and another aspect, such as population health, added. Such changes would be made in order to align with new organizational priorities. In addition, as revisions are made to the CCHSA standards or as key areas of focus develop in healthcare, the tool may be refined accordingly.

The Ottawa Hospital Receives Full Accreditation

In July 2004, the Ottawa Hospital (including the Regional Cancer Centre) and its affiliates, the University of Ottawa Heart Institute and the Rehabilitation Centre, announced that they have been granted full accreditation by the Canadian Council on Health Services Accreditation (CCHSA). This is the highest accreditation level granted by CCHSA, awarded to fewer than half the organizations surveyed.

An additional benefit is providing teams with the opportunity to work with the standards and understand their intent and requirements outside of the regular accreditation selfassessment process. By using the abbreviated tool tied to the organization's quality framework, teams may monitor and improve performance on a regular basis and will know if their CQI initiatives are working, resulting in the highest quality of patient care. It will also shorten the normal length of time required to orientate teams to the standards at the outset of each survey process, and will allow the organization to allocate resources more wisely, avoiding the high costs of "gearing up" for an on-site survey. As well, the use of the abbreviated tool on an ongoing basis will familiarize the teams with the process of self-assessment against the standards.

Next Steps

At this time, our survey teams have completed their intensive self-assessment and documentation process. The documents have been submitted to CCHSA in preparation for the 2004 site survey visit. Our nonsurvey teams are in the process of completing the non-survey assessment tool. Its value to the organization and the required adjustments necessary to ensure its usefulness are undergoing evaluation. Ongoing dialogue with the co-leaders of the nonsurvey teams is in place. A formal assessment of the approach and outcomes will be conducted in the fall of 2004. Our goal will be to learn what worked well and where improvements are required, and then modify the approach as necessary. The teams would complete the template annually between January and March, identifying their QI objectives for the next fiscal year. The initial reaction from several teams is that the tool enables them to identify what they have in place and assess what other elements they need to either improve or implement and overall it provides a useful mechanism for them to focus their QI initiatives.

We are committed to refining an assessment tool utilizing the CCHSA standards in order to effectively integrate the standards into the organization on an ongoing basis. As we have outlined, there are several clear benefits for teams and healthcare facilities.

One possible barrier to address is the perception of additional workload for teams. They may feel that the tool adds additional paperwork. However, the authors believe this process may facilitate the identification and/or assessment of the QI initiatives that already are occurring in our facilities, and mitigate duplication of data collection and reporting activities. Teams will also adopt a culture of continuous quality improvement based on the intent of the AIM accreditation programs. We also suggest that this activity will in the long run save time by facilitating a coordinated approach throughout the organization for QI, and enabling a streamlined and effective preparation process for the formal CCHSA survey.


This approach, conducted annually and then reviewed in an ongoing way by clinical teams, provides a practical and dynamic process and tool. It creates a mechanism by which QI initiatives can be identified, assessed and then aligned with the organization's annual strategic objectives for QI. The tool's flexibility ensures its relevance year after year. As well, it integrates the value of the accreditation standards into the ongoing business of all teams in the organization. Ultimately, this approach should decrease the intensity of preparation required by the organization for each site survey process. While this innovative approach has been uniquely developed within an acute care hospital, we believe it is adaptable and feasible for use in any healthcare organization undergoing accreditation and applying the CCHSA standards.

Please direct correspondence to: Tena McLellan, Director Quality, Directrice de la qualité, The Ottawa Hospital/L'Hôpital d'Ottawa; phone: 613-798-5555 x16695, e-mail

About the Author(s)

Wendy Nicklin, RN, BN, MSc(A), CHE, is Vice-President Nursing, Allied Health, Clinical Programs and Patient Safety at The Ottawa Hospital and a surveyor with the Canadian Council on Health Services Accreditation.

Tena McLellan, RN, BN, MA, CHE, CPHQ, is Director of Quality at The Ottawa Hospital and manages the hospital's accreditation process.

James A. Robblee, BSc, MBA, MD, FRCP(C), is the Chief, Division of Cardiac Anaesthesiology at the University of Ottawa Heart Institute, and a surveyor with the Canadian Council on Health Services Accreditation.


Canadian Council on Health Services Accreditation. 2004. AIM: Achieving Improved Measurement Accreditation Program.

Donabedian, A. 2003. An Introduction to Quality Assurance in Health Care. Oxford: Oxford University Press.

Dukes, A. 2002. "The New Survey Process Will Surprise You." ED Management 136-137.

Wagner, C., L.H De Bakker, H. Dinny and P.P Groenewegen. 1999. "A Measuring Instrument for Evaluation of Quality Systems." International Journal for Quality in Health Care II(2):119-130.


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