Questions about a specific ROP or need guidance? Contact the accreditation team:

📧 [email protected]

✅ Included: You are the primary owner of this practice, or a key collaborator who would be expected to articulate your department's role in ensuring compliance.

❌ Excluded: ROPs that are tangentially related to your area but that a surveyor would not realistically direct at your department. For example, the Workplace Violence ROP applies to HR and Senior Leadership (who own the policy and program), not to every manager across the organization — even though all staff are affected by it.

1. Each ROP was reviewed against its Accreditation Canada standard, tests for compliance, and the type of evidence required.

2. Departments were aligned to SJHCG's actual leadership structure and the roles that would interact with surveyors.

3. Cross-references were made with the SJHCG Master Evidence Binder to verify which departments own or contribute to the required evidence for each ROP.

4. Mappings were kept intentionally tight to avoid giving leaders unnecessary prep work or reducing confidence in the tool.

Even if a ROP doesn't appear under your department filter, surveyors may still ask any leader general awareness questions like "What do you do if you witness a patient safety incident?" or "How do you practice hand hygiene?" The filtered ROPs are the ones where you need to articulate your area's specific compliance approach, not just general awareness.

Some departments (e.g., Finance, IT, Health Records) are not listed because no ROPs would be specifically directed at those areas by a surveyor. If you're in one of these areas, you're not expected to prep for specific ROPs, but you should still have general awareness of patient safety practices (hand hygiene, incident reporting, etc.).