Accreditation levels of effort and recognition
The tools used for the survey include among others, the standards and assessment tool kit which are organized in a framework of five risk areas:
- leadership process and accountability,
- Competent and Capable workforce,
- Safe environment for staff and patients,
- Clinical care of patients and
- Quality improvement
Three levels of effort are a required measure to reach expectations for each standard:
- Level I: Requires developing and communicating policies, procedures, and plans which describe the level of quality expected in all areas within the facility.
- Level II: Involves implementation of policies, procedures, and plans that were developed in Level I.
- Level III: Requires monitoring of the effectiveness of the processes implemented in Level I At this level, data must be used as evidence to identify opportunities for improvement, and thus action plans for improvements need to be developed.
The following criteria are currently used to determine Level I, II and III recognitions:
| Level I Recognition | Level II Recognition | Level III Recognition |
| 1. The overall average score of 85% at Level I | 1. Level I recognition must be achieved and maintained Overall average score of 75% at Level II | 1. i. Level I & II recognition must be achieved and maintained ii. Overall average score of 70% at Level III |
| 2. The average score of 75% for each risk area at Level I | 2. The average score of 70% for each risk area at Level II | 2. The average score of 60% for each risk area at Level III |
| 3. The overall average score of critical standards of 80% at Level I* | 3. i. Level I critical standards are met at 100% 3. ii. The overall average score of critical standards of 80% at Level II* | 3. The overall average score of critical standards of 100% at Level III* |
- Critical standards are required by national laws and regulations and, if not met, may cause death or serious harm to patients, visitors, or staff.