During the Accreditation Canada survey, Ts'ewulhtun staff learned a great deal about building good relationships with the surveyors who visited over several days to assess the quality of programs, services, safety, infection prevention and control, effective organization and governance.

Other Achievements

  • The quality and safety of health care for community members continued to remain a priority at the Health Centre following the accreditation survey.  Staff and leadership met regularly to learn from one another and identify, monitor and discuss quality improvements such as: integrating the Cowichan teachings in policy and practices; creating checklists and procedures for better communication and community input; and clarifying staff and leadership roles and responsibilities.
  • The incident reporting and disclosure process became embedded in the organization as staff learned the value of identifying and tracking safety concerns to continually improve the delivery of health care.  The system also increased awareness about the importance of using policy and integrating processes to follow up on actions with other Cowichan Tribes departments.
  • Organizational effectiveness continued to improve through regular interactive staff meetings and training to share best practices for quality improvement and safety.  The planning, policy and best practices framework was further developed as a tool for documenting and updating policies and procedures.
  • Relationships were built with other First Nations and health organizations through participation in regional and national networking groups, such as the First Nation Inuit Health and Accreditation Canada.  This created opportunities to share best practices and information.


Organizational growth and change is a process that requires time and effort on the part of individuals as well as teams and leadership.  It was a complex process to coordinate the planning, policy development, and training and education needed to ensure that the requirements set by Accreditation Canada Standards would be met.  Developing open and timely communications and an inclusive process was difficult due to busy schedules and established routines.  However, finding ways for staff and leadership to contribute their valuable knowledge and experience for achieving meaningful improvements was essential.


  • Further weave culturally-safe care into planning, processes and daily service delivery.
  • Prepare for mid-cycle survey visit with Accreditation Canada in June 2014 by evaluating our initiatives, programs, services and health governance.
  • Implement a quality improvement and safety plan that is guided by the Cowichan Teachings, best known practices and the knowledge and experience of staff, community members and health partners.


  • Support staff as they continue to identify areas for improvement for quality and safety, including any training needs.
  • Strengthen and streamline processes for community members, staff and leadership to identify priorities for improving quality and safety.  Establishing priorities for improvements, as well as indicators to measure progress, will help to ensure that services meet high standards.
  • Develop information management systems that will provide better access to policy, planning and working documents.
  • Work with new First Nations Health Authority was well as community partners to strengthen the continuum of care and health governance.

In June 2012 Ts'ewulhtun Health Centre achieved its goal of becoming an accredited health centre after several years of hard work by staff and leadership.  The Health Centre was awarded the highest award given out by Accreditation Canada - Exemplary Standing!