Local Advisory Services

Continuous, hands-on local support for Accreditation Canada partner healthcare organizations in Georgia, throughout the whole accreditation cycle.

Who these services are for

Local Advisory Services are available only to healthcare organizations that have a contract with Accreditation Canada. They are delivered by the Accreditation Canada Tbilisi Office, which is operated by the Public Health Institute of Georgia.

Don’t have a contract yet? See how the process starts or contact us.

Every service is an offer. Your organization decides which services it takes up and when, and may decline any of them, in whole or in part, at any time.

An agreed service is used in its month. If the organization cancels it or does not take part, the service counts as delivered and is not carried forward.

At a glance: what your organization receives every month

Dedicated Accreditation Coordinator

One full working day on site and up to two online working sessions a month; day-to-day coordination; management of documents and evidence and their upload to the Accreditation Canada platform.

Expert support

Access, through the Coordinator, to the Tbilisi Office team of 10 experts as needed.

Online training

Two online training programmes a month on GMJ Academy, open to all staff, with individual log-ins and certificates.

In-person training

One on-site session every quarter, building on the online courses staff have completed (blended learning).

Patient Voice Package

A monthly Patient Council meeting, a patient feedback system with a monthly report, and an Independent Patient Ombudsman service.

Publications

Up to two publications a month on sheniekimi.ge showcasing your organization’s good practice.

Remote technical support

Ongoing, throughout the accreditation process.

Periodic services

In-person training (quarterly); environmental monitoring (twice a year); SOPs and technical documents; one full-day accreditation visit simulation. Scheduled in the annual plan.

Who delivers what

All Local Advisory Services: Accreditation Canada Tbilisi Office, operated by the Public Health Institute of Georgia
Online training: GMJ Academy (individual log-ins and certificates)
In-person training: Institute trainers, on site at your organization
Patient Voice Package: Managed by the Public Health Institute of Georgia: Patient Council secretariat, feedback system and ombudsman
Publications: sheniekimi.ge, Georgia’s health news platform

Services in detail

The purpose of these services is to support your organization at every stage of the accreditation cycle: implementing standards, preparing documentation and evidence, preparing staff, engaging patients, coordinating technical matters and getting ready for the Accreditation Canada assessment.

Dedicated Accreditation Coordinator

Many hospitals in Georgia cannot afford, or cannot justify, a full-time accreditation coordinator on their own payroll. That is exactly the gap the Tbilisi Office fills: it assigns a Dedicated Accreditation Coordinator to your organization for the whole accreditation process. The Coordinator is your operational and technical focal point and your contact person with Accreditation Canada.

The Coordinator provides

one full working day on site at your organization each month, and up to two additional online working sessions;
day-to-day planning, coordination and follow-up of accreditation activities;
organization and management of all documentation and evidence, uploading it to the Accreditation Canada platform and linking it to the relevant requirements;
answers to, or clarification of, technical questions about the process and requirements;
identification of gaps, assessment of how standards are being implemented and follow-up of required actions during the monthly on-site day;
tracking and resolution of outstanding documentation, evidence and technical issues.

What your organization provides

Your organization appoints one internal focal person, for example a quality manager or deputy director, who coordinates accreditation activities inside the hospital and is the Coordinator’s day-to-day counterpart. This does not need to be a full-time post, but it must be one named person with the authority to convene staff, obtain documents and follow up actions internally. Without an internal focal person the service cannot be delivered effectively.

Role during the assessment

The Coordinator works on your organization’s side. During the official Accreditation Canada assessment, the Coordinator represents your organization in front of the surveyors, not Accreditation Canada. To keep the assessment independent, the Coordinator will not act as a surveyor of your organization or as an interpreter for the survey team. This assignment is formally declared to Accreditation Canada under its conflict-of-interest procedures before the assessment takes place.

Expert support from the Tbilisi Office

In addition to the Coordinator, your organization has the full technical support of the Tbilisi Office and its team of 10 experts. The Coordinator brings in the right expertise according to your needs and accreditation stage.

Online training through GMJ Academy

Two online training programmes a month on academy.gmj.ge.

More detail

All staff may take part; there is no limit on the number of participants.
Each participant receives individual log-in details.
Training is online and self-paced.
Topics include accreditation standards, quality improvement, patient safety and related subjects.
Participation and completion are tracked on the platform; a certificate is issued on completion where the course provides one.
The two programmes allocated to a month do not carry over to later months if unused.

In-person training (quarterly)

Once every three months, a Tbilisi Office trainer runs a session at your organization that builds on the online courses completed during the quarter, so that e-learning and face-to-face practice reinforce each other.

More detail

One session per quarter, normally in months 3, 6, 9 and 12 of the annual plan.
The topic is agreed with your organization in advance, linked to completed online courses and current priorities.
A practical, case-based format: discussion, exercises and applying the standards in your own setting.
Open to all staff who have completed the related online course; your organization provides the room and confirms attendance.

Environmental monitoring

A technical and visual assessment of corridors, toilets, waiting areas and other spaces used by patients, covering the hygiene and safety aspects relevant to accreditation. Twice a year (normally in months 2 and 8), each followed by a short written report of findings and recommended actions.

SOPs and technical documentation

The standard operating procedures, policies, templates, forms, guidelines and other documents needed to implement the applicable accreditation requirements, provided progressively according to need and accreditation stage.

Accreditation visit simulation

A full simulation of the accreditation visit in your real working environment: assessing readiness, identifying remaining gaps and preparing staff and teams for the official assessment. One full working day, normally in month 11.

Publications on sheniekimi.ge

Up to two publications a month on sheniekimi.ge presenting your organization’s successes, Patient Council activities, innovative services or examples of quality improvement and good accreditation practice.

Remote technical support

Ongoing remote support throughout the accreditation process, coordinated through the Coordinator and the Tbilisi Office.

Patient Voice Package

One service, delivered continuously every month, that brings together the three ways your organization hears and responds to its patients. The three parts work as one cycle: feedback and ombudsman themes are reported to the monthly Patient Council meeting, the Council agrees actions and the secretariat follows them up. The package is managed by the Public Health Institute of Georgia.

Feedback and ombudsman
Council meeting
Agreed actions
Follow-up

Patient Council secretariat

Membership: patient and community members, one representative of the hospital and one representative of the Institute, who acts as secretariat and convenor.

Meetings: once a month, at the hospital or online, as Council members prefer.

What the secretariat does

prepares the agenda, invitations, materials and minutes, and follows up decisions;
presents the monthly patient feedback report and leads the discussion of findings;
helps the Council agree concrete actions and tracks whether they are carried out;
runs short learning sessions for members on patient rights, patient safety, accreditation standards and how a Patient Council works;
brings in relevant ombudsman themes in anonymized form;
maintains the Council’s formal structure and documentation as accreditation evidence.

Your organization provides its representative and, for in-person meetings, a room. All technical, logistical and administrative work is done by the secretariat.

Patient feedback system and monthly report

Channels: paper forms, electronic forms or QR codes displayed in wards, waiting areas and at discharge, in whatever mix suits your organization.
Management: form design, printing or online set-up, and secure collection and handling of responses.
Analysis: a structured report with findings and recommendations to support quality improvement.
Frequency: feedback is collected continuously; a report is produced every month and discussed at the Council meeting and with management.

Independent Patient Ombudsman

As an independent organization, the Institute acts as a Patient Ombudsman for the partner organization. Patients and families can contact the service directly, by phone, online or in person.

the patient’s first, independent point of contact, separate from hospital management;
listens, records the concern and clarifies what the patient actually wants;
mediates between the patient and the organization and helps reach a fair resolution;
keeps the patient informed and closes the loop once the matter is resolved;
reports anonymized themes and trends to the Council and to management.

Why this matters

Most patient complaints start with a breakdown in communication, not with the care itself; in our experience, around nine in ten can be resolved through timely, open dialogue. A patient who feels unheard is far more likely to turn to social media or the regulator, where the damage to an organization’s reputation is much greater and harder to repair. An independent ombudsman gives patients a trusted place to be heard, raises confidence in the organization and gives management the chance to fix problems early and quickly.

The monthly rule

Services are planned according to your organization’s accreditation stage, its priorities and the agreed monthly work programme.

Services are offered, not imposed

Every service is an offer from the Tbilisi Office. If your organization says it does not need a service, that service is simply not scheduled.

Monthly planning

Each month, the Coordinator and your organization agree in advance which services will be delivered: the on-site day, online sessions, training, meetings, reports and monitoring visits. Once they are agreed, the Tbilisi Office commits staff, experts and time to deliver them.

A service that has been agreed and scheduled for a month counts as delivered for that month, whether or not your organization uses it. It is not carried forward, accumulated or replaced by another service.

Examples

If a scheduled meeting, on-site day or training session is cancelled or postponed by your organization, or staff do not attend, for any reason, that service is used up for the month.
If the Coordinator or an expert arrives on site as agreed and the organization is not ready to work, the on-site day counts as delivered.
If two training programmes are made available in a month and staff do not enrol, that month’s training is used up.
A service your organization declined in advance and that was never scheduled is not “lost”: it was simply not taken up.

This rule keeps accreditation work on a steady rhythm and protects both sides’ planning.

The 12-month programme

At the start of the cooperation, the Tbilisi Office and your organization agree a 12-month programme. Select a month to see its focus and expected outcome. The order may be adjusted by mutual agreement.

Every month Coordinator on-site dayUp to 2 online sessionsRemote support2 GMJ Academy coursesPatient Voice PackageUp to 2 publications

Month 1 of 12

Focus and periodic services

Baseline review; accreditation workplan; set-up of feedback channels (paper, electronic, QR), the Patient Council and the Ombudsman contact line; documentation and evidence mapping; SOP priorities.

Expected outcome

12-month workplan agreed; priority gaps and the document plan established.

In-person training Environmental monitoring Visit simulation

Coordination

All services are coordinated by the Dedicated Coordinator and the Tbilisi Office on one side and by your organization’s appointed internal focal person on the other. Together they agree priorities and activities according to your accreditation stage and operational needs.

If your organization needs additional services beyond the agreed programme, including a service it previously declined or did not use, they can be requested subject to availability and prior agreement with the Coordinator or the Tbilisi Office.

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Accreditation Advisory Services in Tbilisi, Georgia

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How to cite this page

Accreditation Canada – Georgia. Accreditation Advisory Services in Tbilisi, Georgia [Internet]. Tbilisi: Public Health Institute of Georgia; 2026 [cited 2026 Sep 24]. Available from: https://accreditation.ge/en/advisory-services/

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