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Accreditation preparation guide & resource for volunteers

Sunnybrook Health Sciences Centre (SHSC) will be having an Accreditation site visit during the week of Nov 27 – Dec 1, 2017. The information in this guide is to help volunteers be prepared, comfortable and provide you with information that is important to review.

Accreditation involves everyone at Sunnybrook! Everyone’s engagement in accreditation activities is invaluable in helping to provide high quality and safe care on a daily basis!

Accreditation basics

What is Accreditation?

Accreditation is a voluntary peer review process led by Accreditation Canada that evaluates the hospital against national standards of excellence. The accreditation process helps hospitals identify what is being done well and what needs to be improved.

What is Accreditation Canada?

Accreditation Canada is the national accrediting body for health services in Canada; it is an independent organization that consults with experts to develop health care standards that are based on current evidence and best practices.

Why is Accreditation important?

Undergoing Accreditation demonstrates Sunnybrook’s commitment to meeting the highest standards of care delivery and ongoing quality improvement.

What should I expect when the surveyors are at Sunnybrook?

An accreditation survey day is no different from a regular day. During an on-site visit, surveyors come to Sunnybrook and follow (trace) the path of either a patient or an administrative process from beginning to end. They may ask questions; observe patient care; or administrative processes. We do not expect them to be interviewing volunteers, however, in some areas they may stop to chat with a volunteer. To be prepared and comfortable if that should occur, Volunteer Resources (VR) is providing you with information that is important to review. The Surveyors are not here to test or challenge anyone. This is an opportunity for us to showcase Sunnybrook!

Volunteer checklist

What do you need to know?

  • What to do if there was a fire or another emergency like a violent patient or a patient/visitor fall
  • What to do if you become aware of a patient safety issue
  • Infection Prevention and Control
    • Do not come in to volunteer when ill (in compliance with the Healthy Workplace Policy)
    • Clean equipment as needed – e.g. wheelchairs between each patient use
    • Stay off units experiencing an outbreak
    • Get the flu shot and report this to volunteer resources so it can be tracked.
  • Practice good Hand Hygiene: this means wash your hands with sanitizer or soap and water:
    • Upon entering and leaving the hospital
    • Before and after eating and using the bathroom
    • Between each patient contact and before entering any patient’s room

What do you need to do?

  • Volunteers should be in uniform (clean and tidy)
  • Wear your ID badge with photo visible at all times
  • Clean your hands! It’s everyone’s responsibility to engage in hand hygiene
  • Be positive and speak with pride about the work you do! 

**Accreditation is a celebration of our daily work and opportunity to brag about quality and safe care we provide to our patients**

What you may be asked

  • How long have you been a volunteer at Sunnybrook?
  • What do you do as a volunteer at Sunnybrook?
  • What are you proud of that you have done in the past year in your volunteer role?
  • What type of orientation and training did you receive to be a volunteer at Sunnybrook?
  • What do you do to help keep patients safe?
  • Who would you report a patient safety or other safety issue to?
  • What is your role in the event of a fire?

The following are areas of focus for Accreditation, including relevant information for volunteers. Kindly review:

Patient Identification

What does a volunteer do to ensure the correct identity of a patient?

  • Ask patient his/her name.
  • Always check the patient ID band.
  • Check with staff.

Emergency Preparedness

What is expected of a volunteer in an emergency situation?

  • To know the emergency codes listed on the back of photo ID badge.
  • To know the emergency response numbers:
    • 5555—for fire and medical emergencies; or
    • 9-911—for medical emergencies in the Veterans Centre.
  • To take direction from staff in an emergency situation.
  • To know that copies of the Emergency Response Manual are available in each area.

Hand Hygiene and Infection Prevention & Control

What do you do to prevent the spread of infection?

  • Practice frequent and proper hand-washing using soap and water or hand sanitizer—e.g. when entering and leaving the hospital, between each patient contact, before and after eating, and after using the bathroom.
  • Do not come in to volunteer when ill (in compliance with the Healthy Workplace Policy).
  • Clean equipment as needed—e.g. wheelchairs between each patient use.
  • Stay off units experiencing an outbreak.
  • Get the flu shot and report this to Volunteer Resources, so it can be tracked.

Privacy & Confidentiality

How do you ensure confidentiality of patient information?

  • By not sharing information with others about any patient.
  • By not repeating any information learnt about a patient or resident through volunteer activity.
  • By not asking patients about their medical condition and respecting their right to privacy.
  • By ensuring documents with any patient/family information are kept secure or are discarded in appropriate receptacles for confidential information (e.g. Iron Mountain).

Clearly Defined Staff Roles and Responsibilities for Patient Safety

What helps to ensure volunteers can support patient safety?

  • Orientation & training prior to volunteering, which teaches volunteers about:
    • Confidentiality & Privacy, Infection Prevention & Control, Fire Safety & Security, Wheelchair Safety, Wandering Patients, Reporting of Incidents/Safety Reports, AODA, Mission, Vision, Values, Sunnybrook Moments – Patient experience and pertinent policies & procedures.
  • Mandatory Refresher Orientation every five years.
  • Reporting to staff anything that is potentially unsafe, so it can be addressed.
  • Reporting any injuries or incidents of verbal or physical aggression so that a Safety Report can be completed.

Role of Volunteers

What is your role as a volunteer at Sunnybrook?

  • To provide support and service to help improve the patient, resident, family /visitor experience.
  • To work in cooperation with staff to enhance the care that patients receive.
  • To ensure my role does not infringe on the role of staff.
  • To support the hospital through involvement in various fundraising activities of the Sunnybrook Volunteer Association.


As volunteers, what communication do you receive about hospital initiatives and how is it communicated?

  • Volunteer Resources shares important hospital-wide information via e-mail, hard copy notices, and in-person notification.
  • Updates about information specific to volunteers are communicated via a variety of methods, including: monthly Bulletin (electronic and hard copy), group meetings with volunteers and staff, and in-person from staff as needed.
  • Information about and invitations to participate in hospital surveys, recognition events, etc.

Sunnybrook’s Values: Excellence in CARE

Consider how you as a volunteer exemplify these values:

  • Excellence – you strive to do the best you can and ensure a positive experience for all with whom you interact.
  • Collaboration – you work in cooperation with staff and other volunteers to carry out your function as part of a team.
  • Accountability – you are accountable for the role you play and understand that in your volunteer capacity you act on behalf of the hospital and thus are required to follow hospital policies and procedures.
  • Respect – your interactions with others are respectful, you value diversity of others, and are non-judgmental.
  • Engagement – you are involved and committed to your role, you offer and are asked for your input, and you derive satisfaction and enjoyment from your volunteer involvement.

Key Contact for Sunnybrook’s Accreditation 2017

Maggie Ford ext 89823
Accreditation Specialist, Quality and Patient Safety