Accreditation

Accreditation Canada, an independent organization, assesses our services and compares them to standards of excellence to identify what is being done well and what needs to be improved.

The accreditation standards involve everyone in the hospital, from our Board of Directors to frontline staff. The standards also involve members of the community, including patients, their families and community partners.

Why does accreditation matter to patients and families? Simply put, accreditation:

• Improves patient safety
• Prioritizes quality improvement activities
• Creates a culture of quality and safety

Although the site visit is only once every four years, the Accreditation process and quality improvement work is ongoing. This continuous approach enables us to provide high quality care for our patients each and every day. 

Highlights from MGH's 2016 Accreditation Site Visit

In 2016, Michael Garron Hospital (MGH) received Accreditation Canada’s highest recognition: Exemplary Standing. This is recognition that our organization has attained the highest level of performance, achieving excellence in meeting the requirements of the accreditation program. Safety was one of the eight quality dimensions measured in the accreditation process; surveyors noted that the hospital’s culture of openness and transparency with regards to incident reporting created an environment where staff were comfortable discussing patient safety issues.

Leading Practices

MGH has been awarded 34 leading practices by Accreditation Canada. Leading practices recognize solutions that improve quality in health service delivery and must meet a variety of stringent criteria: they must be innovative and creative, client or family-centred, evaluated, able to demonstrate intended results, sustainable and adaptable by other organizations.

MGH leading practices include:

• Antimicrobial stewardship program (2012)
• Post discharge phone call program (2012)
• Timely resolution and sustainable improvement: patient relations (2012)
• Physician activity report (2012)
• Learning management system community partnership (2012)
• Electronic medication reconciliation at admission (2012)
• Hospital-acquired clostridium difficile management program (2014)
• Improving employee engagement through quarterly staff engagement surveys (2014)
• Mental wellness in the workplace (2014)
• Diabetes group walking clinic (2015)
• Patient Videos (2015)
• Electronic Discharge eNotifications (2015)
• Michael Garron Hospital’s ‘Social’ C-Suite (2016)
• Credentialing & Reappointment Process (2016)
• Rounding for Quality (2016)
• Using mobile technology to support patient care at Michael Garron Hospital (2016)
• Aboriginal Day Withdrawal Program (2016)
• ALC Avoidance Framework (2016)
• Using Patient Stories and Reflective Practice to Transform an Organization’s Culture (2017)
• Reducing Length of stay for total knee arthroplasty through enhanced patient education (2018)
• Daily Safety Check (2018)
• Collaborating to Create the Safest Possible Workplace - Workplace Violence Prevention at Michael Garron Hospital (2018)
• Finding the right fit – the 360 simulation based interview (2019)
• 2-Step Urine Culture Ordering in the Emergency Department (2019)
• Treating Clostridium difficile Infection (CDI) with Fecal Bacteriotherapy (FBT) (2019)
• Increasing Recovery Room Utilization through a Merger of Ambulatory Surgery Units at Michael Garron Hospital (2020)
• Creating and Fostering an LGBTQ2S Inclusive Environment (2020)
• Deprescribing at Michael Garron Hospital (2020)
• Michael Garron Hospital's Staff Assessment Centre (2021)
• Improving provider communication and connectivity with Hypercare (2021)
• An Integrated Community Response to COVID-19 Using the Hub and Spoke Model (2021)
• Expanding the Implementation of Remote Patient Monitoring and Virtual Care Pathways Developed during the COVID-19 Pandemic (2021)
• COVID-19 Mobile Vaccination Strategy in High-Incident Neighbourhoods: A Distributive Leadership Approach to Accelerate Collective Local Health Impact (2021)

• East Effort’s Community Health Ambassadors Initiative (2022)

• Michael Garron Hospital's Child and Youth Emergency Zone (2022)

• Recovery Reimagined: Outpatient Substance Use Programming (2022)

To learn more about MGH's leading practices visit the Health Standards Organization (HSO) Leading Practice Library