In short
31 questions across 9 areas for a clinic to check its readiness for an Accreditation Canada survey: governance, documentation, patient safety, incidents, infection control, environment, staff, patient engagement and final preparation.
31 key questions to check how ready your organization is for the surveyors’ visit. Print this page and use it at an internal meeting.
This checklist is general guidance and does not replace the full text of the standards. For a detailed self-assessment, take the readiness check or contact us.
Governance and quality
- A person responsible for quality is appointed and a quality committee meets regularly.
- There is an annual quality and patient safety plan.
- Quality indicators are defined and measured.
- The risk register is up to date and risks are assessed.
Documentation
- Policies and SOPs are approved, versioned and dated.
- Staff know where procedures are kept and how to use them.
- Medical records are complete, legible and completed on time.
Patient safety
- Patients are identified with at least two identifiers before every procedure.
- Medication reconciliation is done on admission, transfer and discharge, and is documented.
- High-alert medications are stored separately and labelled.
- Falls risk is assessed and preventive measures are taken.
- Information is handed over between staff in a structured way (e.g. SBAR).
- The surgical safety checklist is used for every operation.
Incidents
- A non-punitive incident reporting system is in place.
- Serious incidents are analysed (e.g. RCA) and corrective actions are completed.
- Staff receive feedback on the lessons learned from incidents.
Infection control
- Hand hygiene is monitored and results are shared with staff.
- The sterilization process is validated and documented.
- Cleaning schedules and waste management are in place.
Environment and equipment
- Medical equipment is registered and has a maintenance schedule.
- Fire safety and the evacuation plan are checked, and drills are held.
- Signage and information are clear for patients.
Staff
- Staff qualifications and licences are verified and up to date.
- New staff complete orientation, and training is regular.
- Safety culture and staff satisfaction surveys are carried out.
Patient engagement
- Patients are informed of their rights and how to complain.
- Informed consent is obtained fully and clearly.
- Patient feedback is collected and analysed, and a patient council is in place.
Before the survey
- A mock survey and tracers have been carried out.
- Staff are ready for interviews and know the key procedures.
- Evidence (minutes, audits, indicators) is readily available.