These are the Required Organizational Practices released by Accreditation Canada International on 2014.

2. By
Abdalla Ibrahim
Healthcare Surveyor
Accreditation Specialist
May, 2013
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abdallaibrahim@hotmail.com 2

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4. Required Organizational Practices
(ROPs)
Essential practice that organization must
have in place to:
 enhance patient/client safety
 minimize risk.
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6. The Required Organizational Practices
The ROP
 Statement defines the practice that is expected.
Guidelines
 Context and motivation on why ROP is important to patient
safety and risk management.
Tests for Compliance (major and minor)
 Expectations of surveyors during on-site assessment to
determine compliances with ROP.
 Categorized as major or minor.
Reference Material
 Sources of evidence, tools and resources to assist
organizations in meeting tests for compliance.
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7. Pathway of Development
 Developed in 2004 by Patient Safety Advisory Committee
 Developing:
 National and international literature reviews
 Analysis of survey results and compliance rates
 Research with regard to other accrediting bodies
 ROPs Extensive testing and national consultation
 Feedback from expert advisory committees, client organizations,
surveyors and stakeholders
 ROPs reviewed and updated
 New ROPs are developed as recommended by advisory
committees and field-specific consultation.
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8. ROPs categories
ROPs are categorized into six patient safety
areas:
1. Safety culture
2. Communication
3. Medication use
4. Worklife/workforce
5. Infection control
6. Risk assessment
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10. SAFETY AREAS, GOAL AND ROPs
SAFETY CULTURE:
Create a culture of
safety within the
organization
• Adverse events
disclosure
• Adverse events reporting
• Client safety quarterly
reports
• Client safety-related
prospective analysis
e.g.
Failure Modes and Effects
Analysis (FMEA)
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11. SAFETY AREAS, GOAL AND ROPs
Organizational culture
 The collective behavior of humans who are part
of an organization.
 The organization values, visions, norms, working
language, systems, symbols, beliefs and habits.
 The pattern that are taught to new organizational
members as a way of perceiving, and even
thinking and feeling.
 Organizational culture affects the way people and
groups interact with each other, with clients, and
with stakeholders.
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12. SAFETY AREAS, GOAL AND ROPs
COMMUNICATION
Improve effective and
coordinated
communication among
service providers and
recipients of care
• Two client identifiers
• Safe surgery Practices (Sign in,
Time out, Sign out)
• Dangerous abbreviations (Do not Do
List)
• Medication reconciliation:
• at admission
• at transfer or discharge
• Transfer of Client information at a
transition point:
(SBAR: Situation, Background,
assessment and recommendation)
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16. SAFETY AREAS, GOAL AND ROPs
MEDICATION USE:
Ensure the safe use of
high-risk medications
• Concentrated electrolytes
(Ca >10%, Mg> 20%, K >2 mEq/ml,
Na > 0.9%)
• High alert medication: eg.
 adrenergic agent,
narcotics, insulin,
chemotherapy, sedatives,
neuromascular blockaing,
heparine,
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18. SAFETY AREAS, GOAL AND ROPs
WORKLIFE/
WORKFORCE:
Create a worklife and
physical environment
that supports safe
delivery of care and
service
• Workplace violence
prevention
• Client safety plan
• Client safety: Education
and training
• Preventive maintenance
program
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20. SAFETY AREAS, GOAL AND ROPs
INFECTION
CONTROL:
Reduce risk of health
care-associated
infections and their
impact across the
continuum of
care/service
• Hand-hygiene education
and training
• Hand-hygiene audit
• Infection rates
• Pneumococcal vaccine
• Sterilization processes
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22. SAFETY AREAS, GOAL AND ROPs
RISK
ASSESSMENT:
Identify safety risks
inherent in the client
population
• Falls prevention
strategy
• Home safety risk
assessment
• Pressure ulcer
prevention
• Suicide prevention
• Venous
thromboembolism
(VTE) prophylaxis
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