Accreditation

Accreditation is a key priority for Shared Health's diagnostic services because it is the primary evidence that our quality management system is working.

Our commitment to accreditation is in perfect harmony with legislation from the Government of Manitoba that requires all medical laboratory and diagnostic imaging sites in Manitoba to be accredited by a third party agency.

Shared Health uses two third party accreditation agencies for most of its accreditation needs: the Manitoba Quality Assurance Program (MANQAP) and College of American Pathologists (CAP). CAP is one of the highest ranked accreditation agencies for medical laboratories in the world; we're proud that our two largest medical laboratory sites (Health Sciences Centre and St Boniface General Hospital) earned their CAP accreditation in 2011 and have maintained that level of quality ever since. Other Diagnostic Services, Shared Health pathology laboratories were accredited by CAP in 2013.

Shared Health's laboratories and imaging facilities offer different patient services, which determine what accreditations are required for each site. A site may only require one accreditation or it can have different accreditation reports for Transfusion Medicine, Laboratory, and Diagnostic Imaging. The standards and requirements for all of them are rigorous so we are proud that of each accreditation achievement.

Shared Health's combined accreditation status is an amazing achievement made possible by the hard work and dedication of over 1,600 staff across Manitoba. But accreditation is not a goal that is achieved and then forgotten about. Accreditation is something our staff work diligently to maintain on an ongoing basis. Being accreditation-ready all of the time is one of the ways that Shared Health can show patients, the public, and our health care partners that we are truly committed to quality.

For inquiries regarding Shared Health accreditation for diagnostic services, please email: dsmquality@sharedhealthmb.ca.

Frequently Asked Questions

Diagnostic Services, Shared Health accreditation starts with the Program Review Committee (PRC) of the College of Physician and Surgeons of Manitoba (CPSM) setting the standards for medical laboratory and diagnostic imaging services. CPSM/MANQAP staff visit each Diagnostic Services, Shared Health site to measure how well each site is complying with these standards and then they report to the PRC whether the facility being accredited meets or exceeds the standards required by the College.

Both MANQAP and CAP have several thousands of detailed accreditation standards. Like a report card that you would receive in school, it is rare to get 100%. This system is designed for continual quality improvement. Some standards are far more important to patient safety than others; many standards relate to documentation, policy, and procedure manuals. Diagnostic Services, Shared Health takes all deficiencies seriously, but none more seriously than those with a direct risk to our patients. If a deficiency like this is found in an accreditation visit, it is corrected immediately. Fortunately, these deficiencies are rare. Our accreditors hold our feet to the fire to ensure Diagnostic Services, Shared Health responds to ALL deficiencies in a timely way. In some situations, the correction may require significant investment in equipment or renovation to meet the standard and this takes time.

Full Accreditation: The site has met all required standards; no corrective actions are required. Full accreditation often comes after a site has submitted its responses and taken corrective actions.

Conditional Accreditation: The site is accredited, but requires corrective action on some standards. Most sites receive a conditional accreditation at first and full accreditation after responding to the deficiencies by taking corrective actions. Sites are permitted to continue operating while they work on areas for improvements because there is no risk to patient safety.

All Diagnostic Services, Shared Health sites have the required accreditation. Accreditation is an ongoing process, not a one-time requirement, so sites are always in different stages of the accreditation process. With highly trained and skilled personnel across our province, Diagnostic Services, Shared Health is creating a patient-first environment that provides quality laboratory and diagnostic imaging services to support the health care needs of all Manitobans.

Diagnostic Services, Shared Health has been participating in third party accreditation programs for years. Recently Bill 38 requires all health care facilities to be accredited by third party programs, and to make this information available to the public. Diagnostic Services, Shared Health has its own Quality department that manages all our accreditation activities, and Board of Directors has a Quality and Patient Sub-committee that oversees Diagnostic Services, Shared Health accreditation. MANQAP of course monitors Diagnostic Services, Shared Health participation and all reports are sent to Manitoba Health.

Certificates

As per Manitoba Bill 38, the following details are provided on Shared Health diagnostic sites receiving full accreditation after November 2012.


CAP Certificates

Grace Hospital Health Sciences Centre
Seven Oaks General Hospital St Boniface Hospital
Victoria General Hospital Westman Lab (Brandon RHC)

American Board of Forensic Toxicology Certificate

St Boniface Hospital

MANQAP Certificates

Birtle Boissevain Carberry
Patient Service Centre Diagnostic Imaging Diagnostic Imaging
Laboratory Laboratory
Transfusion Medicine Transfusion Medicine
Dauphin Deloraine Erickson
Diagnostic Imaging Diagnostic Imaging Patient Service Centre
Computed Tomography Laboratory
Fluoroscopy Transfusion Medicine
Ultrasound
Laboratory
Transfusion Medicine
Glenboro Grandview Hamiota
Diagnostic Imaging Diagnostic Imaging Diagnostic Imaging
Transfusion Medicine Laboratory Laboratory
Transfusion Medicine Transfusion Medicine
Killarney Melita Minnedosa
Diagnostic Imaging Diagnostic Imaging Diagnostic Imaging
Ultrasound Laboratory Laboratory
Laboratory Transfusion Medicine Transfusion Medicine
Transfusion Medicine
Neepawa Rivers Roblin
Diagnostic Imaging Diagnostic Imaging Diagnostic Imaging
Ultrasound Laboratory Ultrasound
Laboratory Laboratory
Transfusion Medicine Transfusion Medicine
Rossburn Russell Shoal Lake
Patient Service Centre Diagnostic Imaging Diagnostic Imaging
Ultrasound Laboratory
Laboratory
Transfusion Medicine
Souris Ste Rose Swan River
Diagnostic Imaging Diagnostic Imaging Diagnostic Imaging
Laboratory Laboratory Ultrasound
Transfusion Medicine Transfusion Medicine Laboratory
Transfusion Medicine
Treherne Virden Wawanesa
Diagnostic Imaging Diagnostic Imaging Patient Service Centre
Laboratory Laboratory
Transfusion Medicine Transfusion Medicine
Westman Lab (Brandon) Baldur Reston
Chemistry Patient Service Centre Patient Service Centre
Cytology
Hematology
Histology
Microbiology
Transfusion Medicine
Urinalysis