ACCREDITATION 2026 – SAFETY CULTURE

Safety is one of our Accreditation Quality Dimensions. It focuses on creating a culture of safety at Menno Place. The following are our ROPs (Required Organizational Practices) that form the foundation of our safety culture.

If you would like a copy of this information for your review you can download it by clicking here: Accreditation 2026 #2 – Safety Culture. You will also find practice questions at the end of this post. All past Accreditation Bulletins are linked here: Accreditation 2026

ROP 1: Resident Identifiers

Surveyor Question: Are at least two resident identifiers used to confirm the resident is receiving the correct care, service, or procedure?

Answer: Resident photos are available on medication carts/outside resident rooms. Second verification is facial recognition through other staff members, families (if they are present), or by resident stating their full name, DOB (if resident is capable).

ROP 2: Workplace Violence Prevention Program

Surveyor Question: Does Menno Place have a documented and coordinated approach to prevent workplace violence?

Answer: Yes, Menno Place has workplace violence and harassment policies, conducts regular risk assessments, and provides mandatory staff training.

ROP 3: Resident Safety Incident Management System

Surveyor Question: Are there processes in place to review resident safety incidents, recommend actions, and monitor improvements?

Answer: Yes, incidents are reviewed through team huddles & meetings, trend analysis, and quality improvement processes guided by established policies.

ROP 4: Safety Incident Management System

Surveyor Question: What is the process to report safety incidents such as near miss, workplace hazards, and employer incident investigation reports?

Answer: Staff can report safety incidents on Quality and Risk Management (QRM) on Surge. All resident related incidents are reported on Point Click Care- Risk Management.

ROP 5: Resident Safety Incident Disclosure

Surveyor Question: Does Menno Place have a documented and coordinated approach for disclosing resident safety incidents to residents and families?

Answer: Yes, resident safety incidents are disclosed and documented according to the Disclosure of Harm or Near Miss policy (AP 2.28) in Surge.

ROP 6: Preventing Falls and Reducing Injuries from Falls

Surveyor Question: How does the team identify residents at risk for falls and implement strategies to prevent falls and reduce injuries?

Answer: Fall risk is assessed on admission and every 3 months, with individualized prevention strategies and care plan reviews for residents with recurrent falls.

ROP 7: Optimizing Skin Integrity

Surveyor Question: How does the team identify residents at risk for impaired skin integrity and implement interventions to prevent skin breakdown?

Answer: Residents are assessed using the Braden Scale, with individualized interventions, treatment plans, and interdisciplinary supports implemented as needed.

Safety Culture: Sample Surveyor Questions

Question: Do you feel Menno Place promotes a just and no-blame culture?
Answer: Yes, staff are encouraged to report concerns and incidents openly to support learning and improvement.

Question: How are resident safety concerns discussed within your neighbourhood or team?
Answer: Safety concerns are discussed during huddles, meetings, and quality improvement reviews.

Question: What can you tell us about the incident reporting process at Menno Place?
Answer: Staff report incidents promptly on QRM on Surge. We can fill out Near Miss, Incident Report, Employer Incident Investigation, and Workplace Hazard Report.

Question: Can you describe an improvement initiative that has been implemented in your area during the past year?
Answer: A few of the initiatives that took place in the past year are new call bell system, new full lifts, and safety huddles.

Question: Why do you think Near Miss Reporting is important?
Answer: Near misses are reported so potential risks can be addressed before harm occurs.

Question: How would you define a harmful event?
Answer: A harmful event is an incident that results in physical, emotional, or psychological harm to a resident.

Question: How does your team learn from incidents and use that information to improve care?
Answer: We review incidents, identify contributing factors, share lessons learned, and implement actions to prevent recurrence.

 Visit our website for more information on each of these ROP’s