Nova Scotia Health Accreditation

Physician participation is critical for patient safety and to meet accreditation requirements. Please review this document to ensure you are aware and follow these ROPs. 

All of the Required Organizational Practices in the Accreditation Canada Qmentum program have been collected into this handbook. Most apply to more than one health sector or service and therefore appear in multiple sets of standards. The applicable standards sets are identified at the beginning of the ROP or in the table at the end of the handbook.

 This resource covers quality, risk, and safety in healthcare. 

In a culture of patient safety, everyone is encouraged to report and learn from patient safety incident. A reporting system facilitates monitoring and learning from data to prevent recurrences.

Research shows a positive relationship between patient satisfaction with how a patient safety incident is handled by an organization and formal open disclosure. Disclosing in an open and timely manner may maintain the patient’s positive relations with service providers and reduce risk of litigation. Disclosure is required for all patient safety incidents which reach the patient (including where there has been no harm).

Hand hygiene is considered the single most important way to reduce health care-associated infections. Cost estimates of health care-associated infections significantly exceed those related to hand hygiene.

Using two patient identifiers to confirm that patients receive the service or procedure intended for them can avoid patient safety incidents (e.g., medication errors).

Information transfer has been identified as critical in improving patient safety, particularly at transition points - ensuring the accurate and timely exchange of information to minimize misunderstanding.

Research suggests that over 50% of patients have at least one discrepancy between the medications they take at home with those ordered upon admission to the hospital. Many of these have the potential to cause medication related patient safety incidents.

An average of 5% of medication errors are attributable to dangerous abbreviation use. Medication errors can lead to an increase in the length of stay, more diagnostic tests and changes in drug treatment.

Safe surgery checklists play an important role in improving the safety of surgical procedures (e.g., wrong surgery, retained objects) as they can reduce the likelihood of complications following surgery and improve surgical outcomes.

Development of VTE is the most common preventable cause of hospital death. Incidence of VTE can be reduced or prevented by identifying patients at risk and providing appropriate, evidence-informed thromboprophylaxis.

Antimicrobial stewardship programs optimize the use of antimicrobials to improve patient outcomes, reduce the risk of infections including Clostridium difficile, reduce or stabilize levels of antibiotic resistance, decrease drug toxicities, and promote patient safety.

Overcrowding is a system-wide challenge and usually a result of a mismatch between capacity and demand. Evaluating client flow data facilitates development of strategies to meet variations, reduce barriers, and prevent overcrowding.

Educating health care providers about patient safety and enabling them to use this knowledge to build and maintain a safe system is critical to creating the safest health system.

Physicians who are well informed about infection rates are better equipped to prevent and manage infection rates. Use of infection rates may focus on a particular health care-associated infection, or may be service, program or organization wide.

How to find your policies and procedures on Nova Scotia Health’s Policy Portal (aka OP3).