Volume 11 | No. 4 | Jul / Aug 2023 query_builder 2 minutes

Reclassification of accreditation standards risk categories

DAP update


Under established Diagnostic Accreditation Program (DAP) policy, identified nonconformances represent a risk that must be managed within an appropriate time frame. Using a risk/frequency matrix, the DAP has established time frames within which resolution to identified nonconformances must be submitted.

As a program committed to making improvements that enhance patient safety, the DAP has identified a requirement to reclassify the risk categories of accreditation standards and introduce a new category level, critical risk.

Effective September 4, 2023, the DAP is introducing the accreditation standard risk category, critical risk, which has been defined as a nonconformance that presents immediate hazardous or unsafe conditions for patients or facility personnel or pervasive deficiency in the facility, that represents systemic failure leading to unsafe conditions for patients or facility personnel. Critical risk nonconformances require immediate corrective action.

Through consultation with subject matter experts and community feedback, the DAP has identified a number of standards that have been determined to be critical risk. There is a complete list of critical risk accreditation standards for each program:

When a critical risk nonconformance is suspected to represent an immediate hazardous or unsafe condition for patients or facility personnel during an assessment activity, the critical risk nonconformance management process will be initiated:

  1. If the critical risk nonconformance cannot be resolved with an immediate intervention, the deputy registrar, accreditation programs or designate will be contacted to review the critical risk nonconformance and determine if the nonconformance represents an immediate hazardous or unsafe condition for patients or facility personnel.
  2. An emergency meeting will be scheduled between the deputy registrar, accreditation programs, and the facility medical director, and any additional personnel as deemed appropriate by the medical director. The meeting provides an opportunity to review the critical risk nonconformance, evidence observed, and ensure a clear understanding is established about the nature of the identified nonconformance and the immediate risk it represents to patients or facility personnel. The deputy registrar, accreditation programs, will confirm the critical risk nonconformance and review the conditions for the impacted service(s), which may include a mandated pause of the impacted service(s) until the facility is able to provide evidence of corrective action.
  3. The facility will be provided with written documentation of the critical risk nonconformance within two business days.
  4. The DAP staff will immediately review the facility’s response to the report and required evidence submission. Upon successful validation of conformance, the facility will be provided a written confirmation for permission to resume impacted service(s) without condition.

For more information, visit the DAP section of the College website or contact the DAP at dap@cpsbc.ca.