Pathway to accreditation


Phase 1 Phase 2 Phase 3
Phase 1: Readiness (January - April 2020); Phase 2: Improvements and tracing (May 2020 - April 2021); Phase 3: On-site survey (May 2021)
Confirm leads and standards
January 2020
Action plan development and implementation
May – December 2020
Surveyors spend five days at Unity Health Toronto
ROP current state
March 2020
Mini-mock tracers
July 2020 – April 2021
Visit all sites and areas, including LTC
April 13-24, 2021
Table-top planning & full tracers
January – April 2021
Meet with staff, physicians, board, executives, senior leadership, patients and families
OHA governance effctiveness survey
March 2020
Employee engagement pulse survey
May/June 2020AHRQ patient safety culture (Pulse) survey
TBD 2020
Evaluate compliance with standards


Frequently asked questions

Q: Why is Accreditation important?

A: Accreditation demonstrates an organization’s commitment to meeting the highest standards of care delivery. It also helps organizations identify opportunities to further improve their performance for the benefit of their patients and the health care system.

Q: What does it mean to me?

A: Accreditation involves everyone at Unity Health. We all need to be ready to demonstrate Unity Health’s standards and practices related to patient safety and quality.

Q: How does the Accreditation program work?

A: Organizations conduct an extensive self-assessment to determine whether they are meeting standards and where they need to make improvements. The standards examine things like governance, risk management, infection prevention and control and medication management, as well as services in the organization’s specific sector (i.e. acute care, rehabilitation, etc.). Every four years, trained surveyors (experienced health care professionals from accredited organizations) visit organizations to assess whether standards are being met.

Q: How do I know which standards apply to me?

A: Each program and/or service determines which standard(s) apply to their area based on a list of available standards. This determination is made before completing the self-assessments. There are also required organizational practices (ROPs) that are embedded in the standards which apply organization-wide.

Q: Am I able to prepare for Accreditation in advance?

A: Yes! Accreditation is about celebrating the great work we do every day to provide high quality care for patients through best practices and standards. In the spirit of continuous improvement, it is never too early to review the standards and become familiar with how they apply to your workflow or identify areas for improvement. In fact, it is a good idea to review the standards regularly and compare with current practices.