Members from UHN leadership and accreditation teams join surveyors from Accreditation Canada following a successful on-site assessment at the Princess Margaret Cancer Centre, Toronto Rehab and Family Health Team. (Photo: UHN)

Whatever you do, don't call UHN's Accreditation visit a test.

"Celebration? Maybe. Test? Definitely not," says Mike Nader, UHN's Executive Vice President of Clinical Support and Performance and active surveyor with Accreditation Canada for the past 10 years.

Accreditation Canada visited UHN last week, from Sept. 16 to 20.

Celebrating UHN's excellence

Last Friday, TeamUHN members from across the organization gathered at Princess Margaret Cancer Centre for the Accreditation General Debrief. Accreditation Surveyors presented their findings from the week's visit. This was followed by a celebration.

The team reviewed UHN's system standards (organization-wide) including leadership, governance, Infection Prevention and Control and Medication Management and program specific clinical standards at UHN's Princess Margaret, Toronto Rehab and Family Health Team sites.

During the clinical tracers and meetings, surveyors asked a broad range of questions related to best practice standards including: patient and staff engagement, medication management, incident reporting, hospital acquired conditions, hand hygiene, goals and objectives, communication flow, patient flow, admission and discharge processes, etc.

UHN will receive organization-wide Accreditation results upon the completion of the second on-site assessment in September 2021.

As part of the celebration, UHN leadership joined the surveyors in recognizing staff's efforts and commitment to patient care.

"The Accreditation review process is an opportunity for hospitals and staff to see how they're doing in their quality and safety journeys," says Mike. "The surveyors' were impressed by staff's commitment to our patients, willingness to help and commitment to safety, as seen through their participation in daily huddles.

"Their assessments, reinforced what we at UHN already knew – our staff are committed to delivering excellence in care, discovery and learning each and every day."

Creating a culture of quality and safety

This year's assessment was different from previous years.

"In the past, Accreditation was conducted across all of UHN, every four years," says Emily Musing, Vice President, Quality and Safety, UHN. "We moved away from this because we want Accreditation to support continuous quality improvement.

"This time around, Accreditation Canada worked with us to align the assessment process and make it more effective for reviewing organizational standards."

To better support UHN's shared quality and safety objectives, Accreditation Canada revised the way assessments were conducted with smaller, more frequent on-site assessments focused on particular standard sets at UHN.

Accreditation Canada is now assessing UHN during two on-site assessments: September 2019 and September 2021.

Mike, who recently took on a secondment as Chief Transformation Officer at Ontario Health, agrees with the new approach.

"This is an important step in creating a sustainable culture focused on quality and safety," he says. "As healthcare providers, we should always be monitoring and reviewing our clinical practices, not just during the Accreditation period."

Showcasing our commitment to patients and families

"I would like to take this opportunity to recognize all those involved in preparing for September and beyond, including UHN's Accreditation team, UHN's senior leadership team, Patient Partners (who play an integral role in what we do every day), Community Partners, and of course our Princess Margaret, Toronto Rehab, and Family Health Team teams," says Emily.

"We showcased our commitment to improving the lives of patients and families and pride to work at UHN."

If you have any questions please about UHN's Accreditation please email

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