Findings and Recommendations

After our visit to your facility, CorHealth Ontario 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 Achievement. The Certificate is valid for a three year period and we will share a notice of this status with the Ministry of Health and Long-Term Care.

Sometimes, the review highlights the need to address one or more issues before your facility achieves certification. In that case, CorHealth Ontario 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 CorHealth Ontario 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 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 e-mail at eqi@corhealthontario.ca. Completed Quality Improvement Plans should be submitted to the same 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 Criteria for Adjudication of Echocardiography Facilities (2018) provides a detailed overview of how CorHealth Ontario 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@corhealthontario.ca.