ESTRO 2025 - Abstract Book

S2364

Interdisciplinary – Other

ESTRO 2025

Preparation involved creating a governance structure aligned with existing roles, committees, and quality standards; integrating ROPs. Clinical managers / educators played a pivotal role by customizing information and engaging their teams. A self-assessment of over 100 standards was distributed to all clinical staff, identifying a focused action plan. Action plans were aligned to existing committees/roles to support implementation efforts. Mock tracers simulated accreditation surveyors to provide feedback on team’s readiness. Several engagement and educational strategies were embedded in preexisting forums to foster engagement. Leadership received interactive, educational sessions during regular meetings. Data and metrics were aligned with usual quality scorecards and reporting within the hospital. Quality improvement initiatives were highlighted and shared broadly. Patient partners were engaged and central to each quality committee. Results Self-assessment was completed with a 23% (320/1400) response rate. Over 41 action items were developed and aligned to 10 pre-existing committees. At accreditation, 90% of action plans were completed, with one unmet need in outpatient medication reconciliation that had a comprehensive plan to address needs. Two mock tracers were held; with improvements noted from 12% to 74% in compliance. For the on site assessment, over 234 cancer and service excellence standards were assessed, with involvement of 100 inter professional staff. The hospital received a 100% exemplary standing meeting all cancer standards and ROPs; first of its kind rating. Conclusion Embedding quality tactics such as aligning governance within existing frameworks, integrating quality improvement initiatives across departments, using quality discussions across various forums, and incorporating quality metrics into daily communication and dashboard tools has proven crucial for success. As Accreditation Canada moves towards an unannounced assessment model – ensuring sustainability of practice compliance to quality standards through the use of existing support structures has proven to be a successful approach.

Keywords: Accreditation, Implementation Science, Quality