Accreditation 2022

Please note: This information is for the staff and physicians of Unity Health Toronto, and is not for distribution outside of Unity Health. We are using a private section of our external website to allow you easy access to these materials offsite and after hours.


Welcome to Unity Health Toronto’s Accreditation page! At Unity Health, we know the delivery of safe, high quality care requires excellence, teamwork and joy in work – and partnership with our patients, residents and families every step of the way. Like a symphony orchestra, excellence in health care is only possible if each person brings their best performance every day and collectively works together towards a common goal. As we begin our Accreditation 2022 journey, you will find tools and resources here needed to enable us to create the best care experiences for our patients, residents and families every day.

Accreditation Canada’s Qmentum Program

Accreditation Canada logoHealth care accreditation, through Accreditation Canada’s Qmentum program (“Quality and Momentum”) is an ongoing process of assessing health care services against national standards. The goal is to celebrate what is being done well and identify what needs to be improved. The Qmentum program is designed to focus on quality and safety throughout all aspects of an organization’s services, from governance and leadership to direct care and infrastructure for the benefit of patients, residents, staff, physicians and volunteers.

Quality framework

Accreditation Canada evaluates services using the below quality framework. The framework is made up of eight dimensions based on extensive research and expert advice and ensures each standard has a focus on quality. You will see these dimensions when you review the standards, which are meant to help identify the focus of each criterion.

Accreditation Canada quality framework
Dimension Tag line
Safety Keep me safe
Client-centered services Partner with me and my family in our care
Worklife Take care of those who take care of me
Efficiency Make the best use of resources
Appropriateness Do the right thing to achieve the best results
Accessibility Give me timely and equitable access
Population focus Work with my community to anticipate and meet our needs
Continuity Coordinate my care across the continuum

Standards of excellence

Qmentum standards are evidence-based criteria that help raise the bar for improving quality of care in a health care setting. They include four system-wide standards which apply across the organization (i.e. leadership), service excellence standards which apply to specific services and programs (i.e. cancer care), and required organizational practices (ROPs) which are embedded in the standards and apply to all sites and programs.

Phase 1 Phase 2 Phase 3
Completed (check mark)Confirm leads and standards Completed (check mark)Self-assessments Surveyors spend five days at Unity Health Toronto
Completed (check mark)Launch Improvement efforts focusing on ROPs and High Priority Criteria Visit all sites and areas, including LTC
AHRQ Patient Safety Culture (Pulse) Survey
Sept. 2021
Employee Engagement Survey
June 14-21, 2021
Meet with staff, physicians, board, executives, senior leadership, patients and families
Sept. – Dec:

  • Targeted table top planning and tracers
  • Preparation guides and widespread information and education
Evaluate compliance with standards

Frequently asked questions

Q: How has the COVID-19 pandemic impacted Accreditation at Unity Health?

A: Based on Unity Health Toronto’s emergency response to COVID-19, we received permission to reschedule our Qmentum survey, which was originally scheduled for May 2021, to January 2022. Our 2021 Stroke Distinction survey has been rescheduled to Sept. 20 to 22, 2021. Supports and resources have been adjusted accordingly, based on this new timeline and the impact of COVID-19.

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. This commitment to meeting the highest standards of care delivery is an essential part of Unity Health’s mission.

Q: What does it mean to me?

A: Accreditation involves everyone at Unity Health. We all play a role in delivering the highest standards of care to our patients, residents, and families — each and every day.

Q: How does the Accreditation program work?

A: Organizations conduct a series of self-assessments to determine whether they are meeting applicable 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 specific to the organization’s 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 and families through best practices and standards. In the spirit of continuous improvement, it is never too early to review the standards and implement improvement ideas as needed. In fact, it is a good idea to review the standards regularly and ensure your department/team is following best practices. Practicing this type of regular review will make the preparation process less onerous leading up to the survey.

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).


Safety Culture

Creating a culture of safety within the organization


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

Medication Use

Ensuring the safe use of high-risk medications


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

Infection Control

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

Risk Assessment

Identifying and mitigating safety risks inherent in the patient population

Anatomy of a standard

Most Qmentum standards include the following components:

  1. Sections, in all caps and light grey font
  2. The standard, in bold text (i.e. 1.0)
  3. A criterion, in normal font (i.e. 1.1)
  4. Guidelines

Note: surveyors rate each criterion (i.e. 1.1) as it includes measurable elements and defines what is required to achieve the standard. Surveyors do not evaluate guidelines, but guidelines do include helpful suggestions on how to meet the criterion.


System-wide standards

These standards are important in all health care organizations. They include:


These standards address specific types of services and conditions. We are using the following 25 service-excellence standards based on the services we provide:


This standard applies to the Stroke Distinction specialty Accreditation program at Providence. We are using the inpatient stroke rehabilitation services standard based on the stroke services we provide:

What are self-assessments?

The self-assessments are a structured process that help organizations assess their current performance against the standards. A self-assessment is an opportunity for reflection, which helps teams have a discussion about quality and safety, determine which areas require more detailed review and follow-up and inform action planning.

 Self-assessment questionnaire (SAQ)

The self-assessment questionnaire gathers staff perspectives on a variety of topics such as organizational resources and capacity, patient safety and quality, among others. There is no preparation required— staff are simply asked to rate each criteria on a five-point scale based on agreement with the criteria (see example below).

Click/tap image to expand

Good to know!

  • There is no preparation required
  • The SAQs can be done individually or as a group (e.g. Zoom etc.)
  • The SAQ usually takes 1-2 hours depending on the amount of discussion
  • Surveyors do not have access to the results

Self-Assessment Results

Thank you to everyone that participated in Self-Assessments in February! Results have been sent to all teams and are being used to reflect on the criteria and work on Accreditation preparation and readiness.

If you have any questions about the SAQ results or the ROPs/Standards of Excellence for your area, please contact your Accreditation Team Lead or Brian Harvey, Accreditation Lead at 905-359-7832 or As a reminder, surveyors do not have access to the SAQs and we are not evaluated based on the results of our self-assessments. The process is just for us, to help with preparation.

Accreditation updates:

Below you will find updates, videos, successes and opportunities that arise as we get closer to Accreditation.

Accreditation update: June 2021

Staff, physicians and learners at Unity Health have gone above and beyond throughout this entire pandemic – and the past three months have been no exception. We are incredibly proud of you and the care you provide and are grateful to you for your continued dedication.

Over these past few months the Operational Excellence, Patient Safety and Patient Experience teams have been working in the background – alongside content leads for Required Organizational Practices (ROPs) receiving a corporate approach – to continue our Accreditation preparation.

We wanted to share the latest news regarding Accreditation and what you can expect in the coming months.

Survey dates confirmed

  • Stroke Distinction at Providence: Our survey dates have been confirmed for September 20 to 22, 2021.
  • Accreditation 2022 at Unity Health: Our on-site survey dates have been confirmed for January 23 to 28, 2022 (with January 23 as the surveyor planning day and January 24 as the survey start date).

What’s next?

Over the summer we will continue to prepare using our ‘light-touch’ approach. This month we are resuming our monthly virtual Accreditation Forums. Additionally, wrap-around support teams – consisting of Operational Excellence, Patient Safety, and Patient Experience representatives – will begin reaching out to program leaders to provide updates and discuss next steps.  We understand that different teams will be at varying stages of readiness to begin Accreditation preparations again. We are happy to match supports to your current needs and readiness.

Contact information:

If you have any questions, please contact Brian Harvey, Accreditation Lead, at 905-359-7832 or

Last updated June 16, 2021