Accreditation Standards

What are the accreditation standards in SCI acute and rehab care?

In 2012, RHI partnered with Accreditation Canada (AC) to develop comprehensive and evidence-based standards for spinal cord injury called the Acute and Rehabilitation SCI Standards of Care (SCI Standards), as part of AC's existing Qmentum accreditation program, which hospitals sites already participate in. Implementation of these standards through policy and practice changes will help standardize and optimize care for people with SCI in Canada.

RHI's goal is to have at least 50% of the acute and rehabilitation centres participating in the Rick Hansen SCI Registry (RHSCIR) to use the SCI Standards as part of their organizations' Qmentum accreditation site visits by the year 2018.

Accredited RHSCIR Sites July 2016RHSCIR sites which have successfully fulfilled the SCI Standards according to Qmentum accreditation as of July 2016. For a complete list of accredited sites to date, see Status.

How the standards were created

In a joint effort with RHI, AC set up a national Spinal Cord Injury Advisory Committee to assist in the development of the SCI Acute and Rehabilitation Accreditation Standards. The Advisory Committee consisted of experts in the field of SCI across the continuum of care. The Standards were piloted in four Canadian centres:

  • Glenrose Rehabilitation Hospital, AB (Rehab)
  • Ottawa Hospital, ON (Acute and Rehab)
  • Capital Health, Halifax, NS (Acute and Rehab)
  • Saint John Regional Hospital, NB (Acute)

SCI Standards at a glance

The SCI Standards are comprised of criteria with three different levels of priority:

  • Required Organizational Practices (ROPs) address critically important patient safety areas, requiring specific tests of compliance to demonstrate evidence-based practices. ROPs are defined by AC as essential practices (e.g. assessment and management of pressure ulcers or medication reconciliation) that must be in place at the time of the site visit, and are subject to a formal follow-up if not met. ROPs have the greatest impact on an organization's overall accreditation award.
  • High Priority criteria relate to other important themes of safety, ethics, risk management and quality improvement (e.g. training of team members on proper and safe use of equipment, devices and supplies used in SCI services). High Priority criteria that are unmet at the site visit may be subject to a formal follow up, at the discretion of AC. 
  • Other criteria usually pertain to enabling systems within the organization that allow clinical teams to perform well on ROPs and High Priority criteria (i.e. having access to the right resources, physical space and information systems).

Supporting hospitals with their accreditation process

RHI is working to encourage and support SCI centres to adopt the SCI Standards as part of their organizations' existing Qmentum process. Accrediting centres with the new SCI Standards will help ensure that individuals with SCI across Canada are receiving the same level of quality care at any SCI centre.

Standardization of care benefits not only patients, but also the health care system overall by reducing unintended variation in care that is not driven by evidence-based practice, thereby making more effective use of resources, improving patients' health outcomes, and reducing the burden on the healthcare system. This project will encourage centres to adopt best practices and policies that reflect the current state of knowledge and evidence-based best practices for SCI care.

RHI has developed a strategy to spread the adoption of the SCI Standards between 2014 and 2018. This strategy consists of a multi-phased approach including promotion and advocacy of the standards to SCI centres, development of practical tools and resources to aid in implementation of the practices described in the standards, and fostering a community of practice to celebrate and share successes. An AC Toolkit -- available on RHI's clinical resource site SCI2 -- has been developed to help support organizations with implementation of the SCI Standards. The toolkit includes an accessible library of resources that clinicians and policy makers can use to change practice (e.g. clinical practice guidelines, pre-printed orders), and frequently asked questions regarding the accreditation process.


Congratulations to the following facilities who have successfully completed the SCI Standards review as part of their Qmentum accreditation process (as of August 2015).



Date Completed

Queen Elizabeth II Health Sciences Centre, Halifax Infirmary Acute Nov 2013
Queen Elizabeth II Health Sciences Centre, Nova Scotia Rehab Centre Rehab Nov 2013
Hôpital du Sacré-Coeur de Montréal Acute Apr 2014
London Health Sciences Centre, Victoria Hospital Acute Nov 2014
Toronto Rehab, Lyndhurst Centre Rehab Nov 2014
Hamilton General Hospital Acute Jun 2015
Hamilton Regional Rehabilitation Centre Rehab Jun 2015
Winnipeg Health Sciences Centre Acute and Rehab Apr 2016
Foothills Medical Centre Acute and Rehab May 2016
Glenrose Rehabilitation Hospital Rehab May 2016

More information

For more resources, information and toolkits to support the adoption of the SCI Standards, see RHI’s clinical resource website (SCI2) at and download our one page fact sheet.