New process for overdue outstanding mandatory requirements

Questions and answers about the new process for handling overdue OMRs.

What is the new process?

The new process incorporates three steps:

  1. Each month, the DAP will review its records to identify facilities with OMRs that have not been addressed within the time frame indicated in their accreditation report. 
  2. The facilities identified on this report will be sent a letter requiring a status update for the overdue OMRs within two weeks of the letter date. A summary of the overdue OMRs will also be appended to the letter. 
  3. In responding, the facility must send a status update in the form of evidence of implementation or a plan of action.  

Why was this change made? 

Each OMR is assigned a defined timeline for implementation based on the risk associated with the activity, and this timeline is communicated in the report sent to facilities after their accreditation site visit. Overdue OMRs indicate that a facility is not meeting the DAP’s accreditation standards, which are in place to ensure public safety.  

This revised process will help to make facilities and the public aware of the steps taken by the DAP to protect the safety of the public, as well as ensure that overdue OMRs are handled consistently and fairly across all facilities.

What happens if a response is not received?

If a response is not received with the two weeks provided in the first letter, a second letter will be sent to the governing body or owner of the facility. In the case of a health authority facility, this second letter will be addressed to the vice president of medicine and copied to the health authority CEO. A summary of the overdue OMRs and all previous correspondence to the facility staff will be appended to the second letter. 

The facility will be required to submit a status update within two weeks from the date of the second letter. Failure to submit a response at this point will result in the facility’s DAP file being referred to the DAP Committee for reconsideration of the accreditation award.

What if more information is needed?

Facilities are always encouraged to contact the DAP if they have questions. As part of the overdue OMR process, facilities will be offered the opportunity for consultation with a member of the DAP staff.