Phase 2 — Step 5: Report and Quality Improvement Plan


After our visit to your facility, EQI Program staff will provide you with the result of our reviews. If your facility successfully meets the Standard, it is our pleasure to issue you a certificate of accreditation. We will share a notice of this status with the Ontario Ministry of Health (MOH).

Sometimes, the review highlights the need to address one or more issues before your facility achieves accreditation. In that case, EQI Program staff will work with you to address the outstanding issues and/or concerns.

Quality Improvement Plans

A quality improvement plan (QIP) is intended to help you address the issues identified by the on-site reviewers. A QIP is a key component to outlining a facility’s priorities and strategy for implementing quality improvements. You’ll receive a pre-populated template tailored to your facility to help you create your plan. Action items are the backbone of the QIP. Action items address the root cause and operationalize the recommendations.

QIPs serve two important purposes: they are tools for facilities to track the progress of recommendations and their action items; and perhaps more importantly, create an opportunity for facilities to take advantage of a collaborative approach between medical, professional, technical, and administrative staff in identifying a plan that is both effective and sustainable. 

The EQI team provides you with the support you need in this step. For guidance, please send us an email at eqi@iqmh.org. Completed QIPs should be submitted to the same email address.

Appeals

Through the EQI program, we partner with facilities to review them as they relate to the Standards for Provision of Echocardiography in Ontario (2015). The EQI Program Information provides a detailed overview of how the EQI Program conducts on-site reviews and does its assessment of your facility.

The appeals process is to provide echocardiography facilities with fair, timely and consistent process to appeal EQI Program determinations that impact their echocardiography accreditation status or pursuit of echocardiography accreditation.

There are specific points during the EQI Program process where a facility may submit an appeal and it must be done so within the time limits stated in the facility agreement. They are:

  • Upon receipt of a letter and/or report from the EQI Program indicating that a facility is no longer participating with timely and constructive efforts and an associated notice of status change to "not actively pursuing accreditation."
  • Upon receipt of a letter and/or report from the EQI Program indicating procedural non-compliance and an associated notice of status change to "not actively pursuing accreditation."
  • Upon receipt of a letter and/or report from the EQI Program that has found an accredited facility to be in breach of the facility agreement.
     

Appeals will be granted based on procedural concerns, specifically the following:

  • Procedures were not correctly followed regarding the original accreditation review, follow-up review or in the decision to rescind an accreditation.
  • Factual errors in the final accreditation report or letter.
  • Evidence of prejudice or of an undisclosed conflict of interest on the part of one or more of the reviewers, or of the EQI Program review panel involved in the decision.
     

For more information regarding the appeals process, please contact eqi@iqmh.org.

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