Providence Health Care achieves Exemplary Standing in Accreditation

VANCOUVER, May 23, 2014 — Accreditation Canada has awarded Providence Health Care Exemplary Standing, its highest ranking. The designation recognizes Providence as having exceeded the most rigorous requirements of the accreditation program, making it a leader among more than 1,200 organizations representing 5,700 sites and services across Canada.

I offer congratulations to all the health care professional and administrative staff at Providence Health Care for being recognized as a national leader when it comes to providing high quality care,” said Health Minister Terry Lake. “Their hard work and dedication to those in need is an example of the great work being done to support B.C. patients.”

Accreditation Canada is an independent, not-for-profit organization that sets standards for quality and safety in health care, accrediting health organizations nationally and internationally. It is an external peer-review process to assess and improve the services health care organizations provide to their patients and clients based on standards of excellence. There are four levels of awards: Not Accredited, Accredited, Accredited with Commendation, and Accredited with Exemplary Standing.

In November 2013 surveyors performed a review of all of the Providence sites including one-on-one discussions with staff, physicians, patients, clients and their families as well as documentation reviews and conversations with community partners. Surveyors compared the organization’s processes as well as clinical and administrative services against 36 sets of standards. This in-depth process resulted in Accreditation Canada indicating Providence had met 97.5% of over 2,200 criteria across governance, leadership and clinical programs.

Additionally, Providence attained the standards for all of Accreditation Canada’s Required Organizational Practices (ROPs). These are evidence-based practices requiring quality and safety standards in the high-priority areas of safety culture, communication, medication use, worklife/workforce, infection control and risk assessment. Compliance with each ROP test is a requirement in order to attain exemplary status, and Providence met them all.

This achievement is shared by all of our employees who work tirelessly to provide the best care to our patients and residents,” said Dianne Doyle, President and CEO of Providence. “By achieving this status simultaneously across all of our 16 sites, it demonstrates Providence’s steadfast and pervasive commitment to providing the highest level of care to those we serve.”

Providence Chair Geoff Plant said the designation is further validation of the exceptional contributions made by the organization’s staff, physicians and researchers to the BC’s health care system.

Whether it’s in the areas of heart and lung services, addictions, emergency care, or HIV/AIDS through the BC Centre for Excellence in HIV/AIDS and numerous others, our caregivers’ and researchers’ efforts have been noted provincially, nationally and globally. Their contributions benefit all British Columbians and deserve our gratitude. I also want to take this opportunity to thank my colleagues on the Providence board, especially Frank Holler for providing the overall governance and guidance of the Accreditation process.”

In addition to the accreditation survey results, over the past year Accreditation Canada has acknowledged a number of Providence’s initiatives as leading practices in the nation:

  • Reducing the number of routine daily chest radiographs
  • The HIV Peer Navigator Program
  • The Home Parenteral Nutrition Program – Emergency Preparedness Booklet
  • The RACE program (Rapid Access to Consultative Expertise)
  • Palliative care incorporated into chronic disease management
  • Psychosocial Team / Family Information and Support Centre (disaster planning)
  • The Physiotherapy Department’s research, education and practice coordinator
  • (Additional information in Backgrounder).

In their final report, the surveyors noted: “In all areas visited, there was a congenial respectful attitude amongst the staff members and this was demonstrated over and over again in patient-centred responses and approaches to care. Volunteers are also key members of the team and provide invaluable support to patients.”

As a volunteer at Providence, I felt listened to and that my contribution was valuable to the discussion,” said Betty Murray, a patient and family partner with Providence’s Patients as Partners and member of Patient Voices Network. “I came away from meetings knowing that my voice as a family member had really made an impact.”

The Exemplary Standing award is evidence that Providence’s approach to Accreditation and continued quality improvement works. Providence works hard to embed, practice and normalize the high quality requirements of Accreditation in every process and interaction undertaken, rather than treating accreditation surveys as episodic events.


Required Organizational Practices

In the Accreditation Canada Qmentum accreditation program, Required Organizational Practices (ROPs) are evidence-based practices addressing high-priority areas that are central to quality and safety. Accreditation Canada defines an ROP as an essential practice that organizations must have in place to enhance patient/client safety and minimize risk.

ROPs are categorized into six patient safety areas, each with its own goal, as follows:

  • Safety culture: Create a culture of safety within the organization
  • Communication: Improve the effectiveness and coordination of communication among care and service providers and with the recipients of care and service across the continuum
  • Medication use: Ensure the safe use of high-risk medications
  • Worklife/workforce: Create a worklife and physical environment that supports the safe delivery of care and service
  • Infection Control: Reduce the risk of health care-associated infections and their impact across the continuum of care/service
  • Risk Assessment: Identify safety risks inherent in the client population

For more information on ROPs, Accreditation Canada, or the Qmentum accreditation program, visit:

Leading Practices

In addition to the accreditation survey results, over the past year Accreditation Canada has acknowledged a number of Providence’s initiatives as leading practices in the nation:


ICU Routine Daily Chest Radiographs

Providence introduced interventions to reduce the number of routine daily portable chest radiographs in a 15-bed Intensive Care Unit. This initiative aligns with client- and family-centered care by improving quality of care through improved efficiency. Providence believes it is important to eliminate interventions that do not benefit patients to reduce costs and help sustain the healthcare system, provided it does not compromise the quality of care. More info:

Peer Navigator Program

No one understands the reality of HIV better than someone who lives with it every day. The Peer Navigator Program’s specially trained members of the community, who are living with HIV/AIDS, act as important role models to others who are learning to cope with the daily challenges of the disease. Developed and launched in 2011, this program is a partnership with Positive Living BC, a non-profit society dedicated to empowering persons living with HIV/AIDS through mutual support and collective action. More info:

Home Parenteral Nutrition Program - Emergency Preparedness Booklet

Patients of the British Columbia Home Parenteral Nutrition Program require intravenous (parenteral) nutrition due to intestinal failure, the impairment of the bowel’s ability to absorb adequate nutrition and fluid. They infuse their nutrition into their bloodstream via an infusion pump through a central venous catheter. Home parenteral nutrition patients are at risk during a power outage or natural disaster because power is required to keep solutions cold and operate an infusion pump. To address patient concerns about disaster planning, the British Columbia Home Parenteral Nutrition Program developed an emergency preparedness booklet. More info:

Rapid Access to Consultative Expertise (RACE)

Providence partnered with the BC Shared Care Committee and Vancouver Coastal Health to create a telephone advice line where family physicians (FPs) call one number and choose from a selection of specialty services for real-time telephone consultation. In the RACE model, the telephone call is routed directly to the specialist cell phone or pager for just-in-time advice. The innovative model of shared care facilitates collaboration between specialists and FPs to improve care for patients with complex conditions. Lack of timely communication and access to specialists’ advice were identified by FPs as a barrier leaving their patients with the options of lengthy wait times for specialist consults or referral to a local emergency room for specialist evaluation. More info:

Incorporating Palliative Care with Chronic Disease Management

Palliative care education was provided to key nephrology and clinical staff, an implementation framework developed, an advisory working group formed and a project coordinator hired to help implement the initiative with the goal of incorporating and embedding procedures into practice. End stage renal disease patients, especially those on hemodialysis, are known to experience high burdens of pain and symptoms that are under-diagnosed and under-treated. The annual mortality rate ranges between 15-25 percent; approximately 25 percent die as an outcome of dialysis withdrawal; approximately 50 percent lack decision making capacity at the time the decision to withdraw dialysis is made and yet, despite this, renal patients tend not to have engaged in advance care planning discussions with their family or care providers. More info:


Psychosocial Team / Family Information and Support Centre

During a disaster, psychological casualties may outnumber the physically injured by as much as 4:1. Eighty percent of these individuals surge on hospitals to get support for themselves, or to find loved ones from whom they may be separated. Disasters are stressful for staff and leaders who may ignore their own needs to attend to patient and community needs. In an effort to minimize the impact of this surge during times of disaster, Providence has supported the development of a disaster Psychosocial Team, a subcommittee of the Emergency Preparedness Program. More info:

Physiotherapy – research, education and practice coordinator

The gap between evidence and practice is real. Indeed, it is estimated that it takes an average of 17 years for only 14 percent of research findings to be adopted into clinical practice (Westfall et al, 2007). Clearly there is a need to help frontline clinicians more effectively incorporate evidence into their daily practice. In order to address this need, Physiotherapy Services at Providence created a practice support structure in 2002 which included the research, education and practice coordinator position. More info:

For more information on Accreditation Canada and its processes visit

Providence Health Care (PHC) is one of Canada's largest faith-based health care organizations, operating 16 health care facilities in Greater Vancouver. PHC operates one of two adult academic health science centres in the province – St. Paul’s Hospital – performs cutting-edge research in more than 30 clinical specialties, and focuses its services on six “populations of emphasis”: cardio-pulmonary risks and illnesses, HIV/AIDS, mental health, renal risks and illness, specialized needs in aging and urban health and is home to the B.C. Centre for Excellence in HIV/AIDS.

For more information:

Dave Lefebvre
Senior Communications Specialist – Media Relations
Providence Health Care
Tel:  604-682-2344 extension 66987
Cell: 604-837-6003 (c)