Required Organizational Practices (ROPs) are evidence-based practices that mitigate risk and contribute to improving the quality and safety of health services. In 2003, Accreditation Canada convened a Patient Safety Advisory Committee to guide the patient safety-related aspects of the accreditation program. This resulted in an ROP strategy that identified priority areas with the first ROPs being integrated into the accreditation program in 2006. Since then, additional ROPs have been identified with input from health care experts including practitioners, researchers, policy makers, academics, and health services providers.
ROP Development and Consultation Process
High priority patient safety areas
- Risks to patient safety are continually identified through partnerships with the quality and patient safety councils, the Canadian Patient Safety Institute, and other domain-specific partners such as the Institute for Safe Medication Practices (ISMP) Canada.
- Accreditation Canada regularly participates in relevant expert panels, research panels, or consultations which inform this work.
- Client organizations, surveyors, and Accreditation Canada Standards Working Groups identify high priority areas.
Literature and environmental scan
- High priority areas are investigated through a detailed literature review of the peer-reviewed research, grey literature, and practices used by international accrediting bodies.
- Also examined are best practices organizations use to mitigate against the patient safety risk in question.
- The financial costs to organizations to implement a prosective ROP are explored, as are associated system costs should harm occur as a result of the patient safety risk.
Expert consultation
- For each potential ROP, Accreditation Canada convenes a domain-specific group of experts that includes practitioners, researchers and health service providers at the provincial/territorial and national levels. For example, the advisory group for medication reconciliation includes members from ISMP Canada, Safer Healthcare Now, the Canadian Patient Safety Institute, provincial quality and patient safety councils, as well as front line staff from leading Canadian healthcare organizations.
- Expert groups advise on the ROP content and tests for compliance, and how the ROP would fit with the program.
National consultation
- Web-based national consultation is sent out to all Accreditation Canada client organizations, surveyors, ministries of health, and national and provincial partners. Participants rate each ROP for intent, clarity, feasibility, measurability of tests for compliance, and importance in driving patient safety.
Accreditation Program Advisory Committee review
- Each ROP is reviewed in detail, discussed, and endorsed by members of the Accreditation Program Advisory Committee (APAC)
Implementation
- Client organizations and surveyors receive information on new ROPs one year before they are evaluated as part of on-site surveys.
- At this time, education for client organizations and surveyors begins that includes regional sessions, webinars, newsletter articles, and sessions at the National Surveyor Conference.
Review/update
- ROPs are regularly reviewed and updated using national compliance results and feedback from client organizations, surveyors, and patient safety partner organizations.