They came, they saw, they were impressed! Last week, 15 Accreditation Canada surveyors from across Canada spent five days observing, talking to patients, clients, residents, staff, physicians, and community members, reviewing documents and understanding how we provide care and services across 42 sites. They evaluated our performance relative to 28 standards of excellence, including 2,974 specific criteria.

On Friday, the survey team reported their findings. The determined we met 96.4 per cent of applicable criteria, including 98 per cent of the 968 applicable high priority criteria. These are amazing results and compelling evidence that we are continually improving our care and services.

The surveyors were impressed by many things. Some of the overall strengths they identified include:

  • Lean management system, including our hoshin kanri planning which links to the provincial health system plan and the commitment to better health, better care, better value, better teams. Surveyors commented on our daily visual management and engagement of staff and physicians in continuous improvement as part of their daily work. The surveyors noted that we have not yet fully implemented lean especially in many of our rural sites and long term care homes but that many staff are interested in learning and becoming more involved;
  • Living our values – I was thrilled to hear the surveyors talk about how committed we are to living our values of respect, compassion, collaboration, excellence and stewardship;
  • Interdisciplinary teamwork– Surveyors observed many examples of people working well together, conducting team huddles as part of their daily work and valuing the contributions of each team member;
  • Learning organization – Surveyors appreciated our relationships with many educational institutions and creative approaches to support learning and evidence-based practice;
  • Innovative human resource practices such as programs related to violence prevention, staff safety and wellness,  orientation, mentorship and workforce diversity;
  • Safety culture – Surveyors said they saw, felt and heard our commitment to a safety culture. They were impressed by the focus on patients and staff safety in team huddles, visual daily management, the regional weekly wall walk and Authority processes;
  • Ethics – Surveyors were impressed by the development and use of our ethics framework, ethics consultation service and application of an ethics lens and ethical decision making to both clinical and organizational ethics issues;
  • Enterprise risk management – Surveyors appreciated our broad interpretation of risk, including infrastructure failures and commended us for our Region-wide unit dose medication distribution system;
  • Integrated quality management – In addition to our commitment to lean and quality improvement events such as rapid process improvement workshops (RPIWs), surveyors noted our focus on continuous improvement as part of daily work. They were particularly impressed by the meaningful involvement of patient and family advisors and advisory councils as well as partnerships with the community, e.g. our rural community councils.

Accreditation Canada surveyors also noted many overall opportunities for improvement, most of which were not a surprise to us:

  • Integration of urban and rural services, including better integration of urban and rural ambulance services to avoid compromising rural access;
  • Need to develop a scope of service document that defines the role and services available in each facility to help us optimize the resources we have;
  • Aging and poorly maintained or neglected facilities – Surveyors recognized that many of our facilities are old and need to be replaced or refurbished but they also feel we can do a better job of routine maintenance;
  • Space management, including provision of space for private discussions with clients;
  • Inadequate information technology, including but not limited to lack of electronic health record;
  • Patient flow – Surveyors noted our long waits in emergency, waits for long term care and other community services and other delays in care. Surveyors observed our opportunity to improve discharge planning, optimize our rural sites and revisit some of our policies related to client placement;
  • Infection prevention and control, including inconsistent compliance with standards related to sterile processing, opportunities to integrate infection prevention and control into our clinical unit and facilities planning and maintenance;
  • Patient safety, especially medication reconciliation on transfer and discharge, consistent use of two patient identifiers, venous thrombolembolism (VTE) prophylaxis, and education of clients and families about their role in patient safety and equipment renewal;
  • Business continuity to ensure we maintain essential services and manage risk when systems fail;
  • Complaint management– we need to make it easier for members of the public to know where and how they can lodge complaints and concerns;
  • Change management – Surveyors noted that Saskatoon Health Region is experiencing many changes and this causes change fatigue and stress for many people.  We need to be conscious of this and support each other through ongoing change.

It is extremely valuable to have fresh eyes examine our Region and provide candid feedback on how we are doing relative to Canadian standards of excellence. It is very rewarding to hear that we are doing many things well. It is also very helpful to have them identify areas for improvement where we need to focus our improvements. The final written report from Accreditation Canada will be provided shortly and we will post it online. It will be important for us to examine the report carefully, to drill down on areas where high priority criteria and six required organizational practices (ROPs) have not been met, and build this into our continuous improvement plans at the organizational, service line, unit and team levels. Some of the ROPs were not met in more than one area.

I am enormously proud of what we have achieved. This is only possible through the hard work of everyone in Saskatoon Health Region. Thank you for your dedication and commitment.

As always I welcome your feedback and advice on these and other matters. I can be reached directly at

Maura Davies
President and CEO
Saskatoon Health Region

See also >> Region meets 96.4 per cent of Accreditation criteria