The Accreditation Canada (AC) Diagnostics ISO 15189 Plus™ Diagnostic Imaging program is growing! In 2023, the provincial government of Newfoundland and Labrador took a significant step by implementing this program for all 42 imaging services sites across the province. These facilities have successfully completed their self-assessments, and the first on-site-assessments are scheduled to take place in the fall of 2024. 

To ensure the highest standards during these assessments, we expanded our pool of Diagnostic Imaging assessors by training 25 new professionals. These trained assessors are well-equipped to evaluate conformance with the AC Diagnostics accreditation requirements, which are based on ISO 15189:2022 Medical Laboratories - Requirements for Quality and Competence. They also encompass additional standards, such as those published by the Canadian Association of Radiologists, Health Canada, CSA, and the Canadian Association of Nuclear Medicine. The training consisted of online modules followed by a comprehensive one-day, in-person workshop.

Among the new assessors is Kate Smith, Director, Diagnostic and Therapeutic Services, Orillia Soldiers’ Memorial Hospital (OSMH) in Ontario, which is already accredited to ISO 15189 Plus™. Kate offers a unique perspective on the accreditation process, having experienced firsthand the transformation it can bring to health care services. Here’s what she had to say about the impact of accreditation: 

Q&A with Kate Smith

Have you noticed a difference in anything when you compare pre-accreditation times to post-accreditation times? 

I have noticed a huge shift in confidence for the frontline staff once they became acclimatized to the QMS (Quality Management System). Many people interpret ISO compliance as prescriptive; I believe the team now interprets it as empowering…Roles and expectations are clear and opportunities for improvement are identified in a timely manner and faster than without the QMS.

What are some of the positive impacts the accreditation process and accreditation requirements have had?

We are fortunate that the same Director oversees Lab and DI…so we have been able to partner on multiple education opportunities through the economies of scale. Both teams as well as other key OSMH personnel have participated in many of AC Diagnostics exceptional, practical quality education offerings. The OSMH Lab team have been instrumental in coaching DI in implementing the QMS. DI was able to create their own version with a clean slate however, the Lab experience was essential to get us going in the right direction.

One of the positive impacts has been promoting MRTs and MLTs as SMEs [subject matter experts]  in the organization. The DI and Lab teams support other departments in process mapping, risk assessments and document management and control. Recently the DI Quality Assistant worked with the Pharmacy group to perform a risk assessment of the sterile and non-sterile compounding areas. The Ontario College of Pharmacists audit went exceptionally well…The Pharmacy team were empowered by seeing a frontline technologist demonstrate their knowledge and expertise. 

Why did you decide to become a DI assessor?

Great question. My background is Mammography and quality. I was a Regional MRT for the Central Region and had the opportunity to provide quality support and oversight for 22 OBSP sites. It was clear that there are many ways to do things that most often lead to the best outcome however, standardization is a proven way to ensure quality. I am a strong advocate for quality and supporter of standardization and systems thinking so it made sense. On a personal note, although the assessors are thoroughly trained and qualified, I think there is value in having the experience from the “assessee” side of the table. Having been through two full assessment cycles, I wanted to supplement the pool of assessors with my experience.  

Do you have any other thoughts you'd like to add?

I was especially grateful for the hard work we did to become accredited prior to the pandemic. When the pandemic hit, we were well organized and able to adapt processes in an agile manner because the documentation and OMNI system were in place. After months of being agile, one of the frontline techs said to me ‘I get it now, I feel like I know what to do’. We have had incredible buy in from the frontline team and they help us identify opportunities for improvement (OFIs).

Acknowledgements

Thank you to Kate for sharing her insights with us. At AC Diagnostics, we consistently witness the positive outcomes that a commitment to quality and the standard set by accreditation requirements benefits hospital services, and patient safety.  It is gratifying to hear firsthand the positive impact of the DI program at OSMH.  

We also extend our gratitude to all the volunteers who stepped up to become DI assessors. We are eager to hear about your experiences during your first assessments!

Continuing the Journey: Expanding Quality and Excellence Nationwide

This success story from Orillia Soldiers’ Memorial Hospital is just one example of how the ISO 15189 Plus™ Diagnostic Imaging program is driving quality and excellence in health care across Canada. As the program continues to grow, so too does its impact on patient care and organizational performance.