Pathway to accreditation



Phase 1 Phase 2 Phase 3
Phase 1: Readiness (Nov. - Dec. 2020); Phase 2: Improvements & Tracing (Jan. - Dec. 2021); Phase 3: On-Site Survey (Jan. 2022)
Confirm leads and standards
Nov. to Dec. 2020
Jan. 11 to 29, 2021
Surveyors spend five days at Unity Health Toronto
Dec. 2020
Action plan development and implementation
Feb. to July 2021
Visit all sites and areas, including LTC
ROP current state
Dec. 2020
Mini-mock tracers (ROPs)
April to Sept. 2021
Meet with staff, physicians, board, executives, senior leadership, patients and families
Table-top planning and full tracers
July to Dec. 2021
Evaluate compliance with standards
AHRQ patient safety culture (Pulse) survey
Feb. 2021


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. We are continuing with the June 2021 survey date for Stroke Distinction. 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.