HealthcarePapers 7(Sp) January 2007 : 58-63.doi:10.12927/hcpap..18674

CCHSA Accreditation: A Change Catalyst toward Healthier Work Environments

Wendy Nicklin and Melissa Barton


Canada has made significant progress in research and policy development regarding work environment issues that contribute to the quality of the work environment in health organizations. In order to successfully achieve the outcomes that healthier work environments can have on providers, patients and the system, more definitive action is required now. The Canadian Council on Health Services Accreditation (CCHSA) is a recognized catalyst of change in health organizations and systems in Canada and internationally. This paper reviews CCHSA's role in contributing to the improvement of the health of work environments in order to improve both the well-being of those working in healthcare and the quality of care being provided to their patients or clients.
The need for a strong focus on a healthy work environment is increasingly acknowledged and respected as fundamental to the provision of safe, effective healthcare. The evidence of the negative impacts of an unhealthy work environment is escalating and making this issue a priority. While some initiatives to improve the work environment have been implemented, it is evident that considerable work remains to be done.

The Canadian Council on Health Services Accreditation (CCHSA) believes in both the fundamental contribution that the quality of the work environment makes toward the health of employees (both the impact of the job on their health and in supporting their personal health promotion) and in the relationship between a healthy workplace and the quality of patient care. A safe and healthy environment for staff is a safe and healthy environment for patients and clients. For example, if staff members have the appropriate lifts required to do the job, the lifting risk is minimized for both staff and clients. Also, if staff members are active participants in planning and decision making, their satisfaction is positively affected, potentially having an impact on staff retention and the quality of care provided.

All staff within the healthcare industry (community through to rehabilitation) require a quality work environment. The combined focus and efforts of healthcare leaders and stakeholders are essential to effectively address this issue.

It is recognized that the health services environment is one of the most difficult within which to work. It is physically and emotionally demanding and poses a high risk of injury. Health service providers have limited control over workload and work schedules. They may also be subject to potential violence. Employment instability due to provincial, regional or organizational restructuring has contributed to increased stress and less effective communication, with obvious impacts on team cohesiveness. Absenteeism and human resource shortages add to the challenge of delivering quality healthcare. The retention and recruitment challenges for all professions within healthcare are a reality requiring strengthened attention and effectiveness. Clearly, the quality of work life and the health of the work environment are critical factors to be respected and effectively addressed.

The Evidence

In the past decade, there has been an explosion of literature providing evidence that action must be taken now. The lead paper by Shamian and El-Jardali effectively summarizes the challenges in the healthcare workplace environment and outlines recommendations on the directions to be taken. The paper by Clements, Dault and Priest outlines the critical importance of effective teamwork. The Registered Nurses' Association of Ontario (RNAO) has undertaken commendable synthesis work within the Best Practice Guidelines. Specifically, the Healthy Work Environments Best Practices Guidelines Project (led by the RNAO and funded by the Ontario Ministry of Health and Long-Term Care working in partnership with Health Canada and the Office of Nursing Policy) will result in six guidelines including systematic literature reviews.

Strategies to improve healthcare working conditions have been identified. Accountability must now take over - accountability of all key stakeholders to move forward and implement the necessary improvements.

CCHSA and Quality of Work Life

This paper outlines the commitment of the CCHSA and the strategies being used in order to improve quality in health services and to raise the bar for the improved health of healthcare work environments. The vision and mission of CCHSA reflect this commitment to quality. CCHSA's corporate values include reference to quality of work life, for CCHSA staff and the surveyors, as well as within the broader healthcare environment.
CCHSA Vision:
The leader in raising the bar for health quality

CCHSA Mission:
Driving quality in health services through accreditation

All of CCHSA's work is national in scale and is developed to be applicable to most healthcare organizations throughout the continuum of care, including both public and private. The CCHSA standards are standards of excellence, not basic standards. The goal is to enable and encourage organizations to improve, to "raise the bar."

CCHSA is a world leader in identifying work life as a key component of quality for healthcare organizations. In 1999, work life was incorporated into the accreditation program. At that time, work life was identified as one of the four quality dimensions within the definition of quality, resulting in the introduction of work-life standards. CCHSA accreditation standards are continuously improved through a comprehensive consultative process that includes literature reviews, expert advisory committees and key individual interviews in the healthcare field.

The CCHSA Work-Life Strategy

Several years after the 1999 introduction of work-life standards, CCHSA undertook a review of all recommendations from the 2002 accreditation surveys. Two of the top 10 compliance issues noted by the surveyors were related to work life. Nearly 200 recommendations were made about human resources planning, specifically addressing the need to plan, anticipate and respond to current and future human resources needs. In response to this review, six work-life seminars (supported by the Office of Nursing Policy at Health Canada) were held across Canada, with 370 attendees. The information from the seminars provided valuable direction to the CCHSA and led to the next phase of the work-life strategy. This was approved by the CCHSA board in 2004.

The CCHSA Worklife Advisory Committee was convened, and under its guidance the work-life model was developed and the working definition of work life revised. CCHSA based the further development of work-life standards on the following definition: "The organization provides a work environment that enables optimal individual, client and organizational health and outcomes." The CCHSA work-life model takes a comprehensive and strategic approach to work life as it includes organizational factors, care and service processes, staff characteristics and patient characteristics, and their impact on staff, organization and patient outcomes. Some key areas that the accreditation program addresses in relation to this expanded model include culture, open communication, decision-making participation, learning environment, work and job design (which includes issues such as span of control and staffing effectiveness) and supportive physical work environment.

CCHSA has further strengthened the work-life standards. These were released in January 2006 and will apply to 2007 accreditation surveys. The number of criteria that measure work life have more than doubled and are distributed across the standards sections.

Quality of Work Life and Patient Safety

In 2004, under the guidance of the CCHSA Patient Safety Advisory Committee, five patient safety goals were identified, one of which specifically references work life. Introducing work life as a patient safety goal further contributed toward raising the profile of the fundamental and strategic importance of addressing work life.

Does Accreditation Make a Difference?

Canadian and international research evidence supports the fact that accreditation is a valuable tool to increase organizational uptake of continuous quality improvement initiatives (Baker 1997; LeBrasseur et al. 2002). Accreditation leads to the enhanced use of indicators, promotes effective change management, improves organizational learning practices, improves communication among teams and facilitates organizational and regional restructuring (Duckett 1983; Lemieux-Charles et al. 2000). In addition, most organizations implement the recommendations arising from their accreditation visit and report (Beaumont 2002). Accreditation contributes to positive change. The next phase of accreditation-related research will include examining its impact on patient and client outcomes.
CCHSA Patient Safety Goal # 5
Create a worklife and physical environment that supports the safe delivery of care/service.

Most policy reports on quality of work life in healthcare recommend working with CCHSA, supporting accreditation activities to monitor and improve the quality of work life for nurses and other health providers. Accreditation is a significant lever and catalyst to propel this agenda forward, to move healthcare organizations toward healthier work environments. Unquestionably, the CCHSA board, staff and surveyors are committed to the importance of this issue and its relationship to quality of care.

Next Steps for the CCHSA and Work Life

The Pulse Survey Tool

In 2005, CCHSA began the development of a "work-life pulse" employee survey tool to complement the work-life standards. While most health organizations conduct a staff satisfaction survey every one to two years, a simpler complementary tool, focusing on key work-life measures, was identified as necessary. CCHSA, in partnership with the Ontario Hospital Association, contracted Brock University Workplace Health Research Laboratory and the Graham Lowe Group to develop the tool. Pilot tested in 17 organizations across Canada, the Pulse Survey provides a snapshot of employee perceptions of key work environment factors as outlined in the CCHSA work-life model. The tool consists of 21 survey measures. It is designed (1) to assist organizations to track and identify issues for further investigation and to identify specific work units that are exemplary or deficient in their quality of work life, and (2) to allow for benchmarking and identification of national leading practices in this area. The Pulse Survey tool is currently undergoing further testing and will be available nationally as part of the accreditation program in the near future.

Accreditation Leading Practices Database

During each accreditation survey, surveyors identify practices that are noteworthy and that should be shared across the country. These are called leading practices. To date, these leading practices relating to the accreditation standards have been summarized in the CCHSA Canadian Health Accreditation Report, the most recent of which was released in June 2006. CCHSA now offers a fully accessible online searchable database of these leading practices on the website. This section of the website will continuously grow and strengthen, improving on our knowledge exchange responsibility and strategy.
From the National Survey on the Work and Health of Nurses

Nearly half of all nurses (48%) who provided direct care reported having ever had a needlestick or other injury from a sharp object (for example, scissors, scalpels, razors) that had been contaminated by use on a patient. One in ten reported having had such an injury in the past year alone. cw_page=AR_1588_E&cw_topic=1588

The Quality Worklife-Quality Healthcare Collaborative

Partnerships are key to effectively addressing pivotal issues such as quality of work life. The Quality Worklife-Quality Healthcare Collaborative (QWQHC) is an excellent example of effective partnerships. During 2004, a meeting of national health organizations was convened by the Canadian College of Health Services Executives. Consensus was achieved on two major points: (1) there is sufficient research evidence to support the need to improve the health of the healthcare environment as well as the quality of work life, and (2) there is insufficient effective action being taken. It was agreed that by working together and involving key experts, an integrated and coordinated pan-Canadian action strategy could be developed. In response to this, in late 2005, 11 national healthcare organizations created a pan-Canadian collaborative that is guided by the work of over 45 experts. CCHSA provides the secretariat support for the QWQHC. It is funded by Health Canada as part of the 2004 Health Accord Recruitment and Retention Fund.

The collaborative is working to develop a pan-Canadian action strategy focusing on improving healthcare workplaces to improve patient care. The QWQHC pan-Canadian action strategy, the topic of a companion paper in this journal, focuses on activities that embrace evidence-informed management practices (including standard indicators, priority action strategies and ongoing knowledge exchange). CCHSA with the QWQHC partners will play a key role in providing leadership and engaging all stakeholders on the sustainable implementation of these activities in an integrated and coordinated way.

Accreditation Leading Practice at Capital Health, Alberta
The Creating Respectful Workplaces Program has been developed to provide information and strategies to help the region interact positively with colleagues, clients, and the public. Six modules have been developed that cover guiding principles and expectations of respectful behaviour; workplace communication; dealing with disrespectful behaviour, abuse, and harassment; strategies for reducing interpersonal conflict; respect for patients and clients; and respecting cultural diversity in the workplace. This strategy enables the organization to educate and "walk the talk" with respect to creating a culture of patient safety and a quality workplace.


The lead articles by Shamian and El-Jardali and by Clements, Dault and Priest set the stage for discussion of this critical healthcare issue. CCHSA is strongly committed to contributing to improving the quality of work life and to improving the health of the work environment for all members of the healthcare team. CCHSA standards and the entire accreditation program are a catalyst supporting and enabling the necessary change.

It is important to emphasize that while the healthcare organizations, national associations and key policy-makers have a significant role to play in addressing the issue, the professions and the individual providers have key roles to play as well. Collectively and individually, all professions and providers are accountable. The respective responsibilities attributable to each group must be assumed in a integrated manner to successfully address this important issue. With the integrated and timely implementation of initiatives, an increasingly healthy healthcare work environment will result in improved quality of work life. The positive measurable impacts of the successes will benefit our patients and clients, providers and the healthcare system as a whole.

About the Author(s)

Wendy Nicklin
President and Chief Executive Officer
Canadian Council on Health Services Accreditation

Melissa Barton
Coordinating Secretariat
Quality Worklife-Quality Healthcare Collaborative
Canadian Council on Health Services Accreditation


Baker, R.G. 1997. Survey on Continuous Quality Improvement in Healthcare. Toronto: Department of Health Administration, University of Toronto.

Beaumont, M. 2002. Research on the CCHSA Efficacy Accreditation Program: Methodology and Results [Master's Thesis]. Montreal: Department of Health Administration, Faculty of Medicine, University of Montreal.

Canadian Council on Health Services Accreditation. 2006. Canadian Health Accreditation Report. Ottawa: Author.

Duckett, S.J. 1983. "Changing Hospitals: The Role of Hospital Accreditation." Social Science and Medicine 17(20): 1573-79.

LeBrasseur, R., R. Whissell and A. Ojha. 2002. "Organizational Learning, Transformational Leadership and Implementation of Continuous Quality Improvement in Canadian Hospitals." Australian Journal of Management 27(2).

Lemieux-Charles, L., N. Gault, F. Champagne, J. Barnsley, I. Trabut, C. Sicotte and D. Zitner. 2000. "Use of Mid-level Indicators in Determining Organizational Performance." Hospital Quarterly 3(4): 48-52.

Registered Nurses' Association of Ontario. 2006. Developing and Sustaining Nursing Leadership. Toronto: Author.


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