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Accreditation Process New Facility

 

New Facility or Service

 

NB: All new facilities and services, within an already accredited facility must proceed through the Initial Assessment process prior to service delivery or patient testing.

 

The following four steps are for all programs; Diagnostic Imaging, Laboratory Medicine, Neurodiagnostics, Polysomnography and Pulmonary Function.

 

Step 1: Facility Information Form

Physicians and facilities intending to provide a diagnostic service must first complete the appropriate Initial Assessment Information Form:

  • Initial Assessment Facility Information Form - Health Authority
  • Initial Assessment Facility Information Form - Community

After the DAP has received the Initial Assessment Facility Information Form, an Accreditation Specialist will contact the facility to confirm receipt of the form.

 

Step 2: Evidence Submission for Distance Review

(NB: This step is not required for Laboratory Medicine)

 

The facility must complete the Evidence Submission for Distance Review form and submit it with the applicable evidence, prior to scheduling an on-site assessment. 

It is strongly recommended that the appropriate program's Accreditation Standards for Initial Assessment are reviewed and used in conjunction with the Evidence Submission for Distance Review form. This is to understand the scope of the suggested evidence.

 

Step 3: On-Site Assessment

After the DAP has received and reviewed the Evidence Submission Package, an Accreditation Specialist will contact the facility to schedule an on-site assessment.

During the on-site assessment, the assessor will review the physical environment; discuss processes with staff and follow up on any outstanding issues identified during the distance review of the evidence submission. 

 

Step 4: Initial Assessment Accreditation Report

Following the on-site assessment, the facility/service will be issued an accreditation report. If the facility is not meeting all of the requirements outlined in the Accreditation Standards for Initial Assessment, these deficiencies will be outlined in the accreditation report and will need to be implemented prior to receiving a Provisional Accreditation Award.

The Provisional Accreditation Award is valid for one year from when the facility/service successfully implements all of the mandatory requirements outlined in the accreditation report.

 

Initial Assessment Accreditation Fees

New Facility - $500

New Service - $200