Accreditation resources

Interpreting the self-assessment results

Sample metric of self-assessment results

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Self-assessment results are categorized using green, yellow or red flags to show areas of strength as well as opportunities for improvement. Following the self-assessments, the first step is to analyze your yellow and red flags, paying particular attention to required organizational practices (ROPs) and criteria that are deemed high priority by Accreditation Canada (through red exclamation marks). It might be helpful to go back to the standard to see which aspect(s) were specifically not met and ensure your assessments are appropriate. For example, if there is a gap, you can determine whether it is an awareness or process gap.

Developing and prioritizing action plans

After interpreting your self-assessment results, the next step is to develop action plans. Developing your action plans helps embed the standards into everyday practices, making them part of how teams work day-to-day.

Continuous improvement: Plan, Do, Study, Act.

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This is the hands-on work of testing change ideas, adjusting them along the way and making sure they work as intended, through plan, do, study, act (PDSA) cycles. To develop action plans, teams are invited to use the Self-Assessment Action Plans template below. Be sure to engage frontline staff and key stakeholders as you develop your plans as they are grounded in hands-on experiences that will enable standards to be sustained long after the surveyors are gone.

Sample action plan template

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Measurement and sustainability

Hierarchy of effectiveness

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As you develop your action plans, it is a good idea to also consider how the standard will be monitored and sustained over time through system-based actions (right). This may include developing or revising standard work, developing and posting measures to monitor compliance, using visual management to reinforce standards in real-time and/or using team huddles to raise and address problems that are solvable at the front line. Performance of the standard can be further monitored at the program level to resolve issues which require cross-departmental collaboration.