Required Organizational Practices (ROPs)

What are ROPs?

ROPs are essential practices that organizations must have in place to enhance patient/resident safety and minimize risk. Each ROP has associated tests for compliance. All tests for compliance must be met for the ROP as a whole to be rated as met. Below is a list of the 29 ROPs that will be evaluated and are grouped into six patient safety areas that are associated with the different system-wide and service excellence standards (ROP and standard relationship chart).

Required Organizational Practices

Safety Culture

Creating a culture of safety within the organization

  • Accountability for quality
  • Patient safety incident disclosure
  • Patient safety incident management
  • Patient safety quarterly reports



Promoting effective information transfer with clients and team members across the continuum of care

  • Client identification
  • The ‘Do Not Use List’ of abbreviations
  • Information transfer at care transitions
  • Medication reconciliation as a strategic priority
  • Medication reconciliation at care transitions (ED, Ambulatory, Inpatient, Long-Term Care)
  • Safe surgery checklist


Medication Use

Ensuring the safe use of high-risk medications

  • Antimicrobial stewardship
  • Concentrated electrolytes
  • Heparin safety
  • High-alert medications
  • Infusion pump safety
  • Narcotics safety



Creating a work-life and physical environment that supports the safety delivery of care and service

  • Client flow
  • Patient safety: education and training
  • Patient safety plan
  • Preventive maintenance program
  • Workplace violence prevention


Infection Control

Reducing the risk of health care-associated infections and their impact across the continuum of care

  • Hand-hygiene compliance
  • Hand-hygiene education and training
  • Infection rates
  • Reprocessing


Risk Assessment

Identifying and mitigating safety risks inherent in the patient population

  • Falls prevention and injury reduction (In-Patient, Long-Term Care)
  • Pressure ulcer prevention
  • Suicide prevention
  • Venous thromboembolism (VTE) prophylaxis