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Accreditation

Accreditation is a key priority for DSM because it is the primary evidence that our quality management system is working. Our commitment to accreditation is in perfect harmony with legislation from the Government of Manitoba that requires all medical laboratory and diagnostic imaging sites in Manitoba to be accredited by a third party agency.

DSM uses two third party accreditation agencies for most of its accreditation needs: the Manitoba Quality Assurance Program (MANQAP) and College of American Pathologists (CAP). CAP is one of the highest ranked accreditation agencies for medical laboratories in the world; we’re proud that our two largest medical laboratory sites (Health Sciences Centre and St Boniface General Hospital) earned their CAP accreditation in 2011 and have maintained that level of quality ever since. Other DSM pathology laboratories were accredited by CAP in 2013.

DSM’s laboratories and imaging facilities offer different patient services, which determine what accreditations are required for each site. A site may only require one accreditation or it can have different accreditation reports for Transfusion Medicine, Laboratory, and Diagnostic Imaging. The standards and requirements for all of them are rigorous so we are proud that of each accreditation achievement.

DSM’s combined accreditation status is an amazing achievement made possible by the hard work and dedication of over 1,600 staff across Manitoba. But accreditation is not a goal that is achieved and then forgotten about. Accreditation is something our staff work diligently to maintain on an ongoing basis. Being accreditation-ready all of the time is one of the ways that DSM can show patients, the public, and our health care partners that we are truly committed to quality.


For inquiries regarding accreditation at DSM, please email: DSMQuality@sharedhealthmb.ca.


Frequently Asked Questions about Accreditation:

What does Accreditation mean?

Accreditation for DSM starts with the Program Review Committee (PRC) of the College of Physician and Surgeons of Manitoba (CPSM) setting the standards for medical laboratory and diagnostic imaging services. CPSM/MANQAP staff visit each DSM site to measure how well each site is complying with these standards and then they report to the PRC whether the facility being accredited meets or exceeds the standards required by the College.

Is Accreditation a “pass” or “fail”?

Both MANQAP and CAP have several thousands of detailed accreditation standards. Like a report card that you would receive in school, it is rare to get 100%. This system is designed for continual quality improvement. Some standards are far more important to patient safety than others; many standards relate to documentation, policy, and procedure manuals. DSM takes all deficiencies seriously, but none more seriously than those with a direct risk to our patients. If a deficiency like this is found in an accreditation visit, it is corrected immediately. Fortunately, these deficiencies are rare. Our accreditors hold our feet to the fire to ensure DSM responds to ALL deficiencies in a timely way. In some situations, the correction may require significant investment in equipment or renovation to meet the standard and this takes time.

What is the difference between “full” and “conditional” accreditation?

Full Accreditation

The site has met all required standards; no corrective actions are required. Full accreditation often comes after a site has submitted its responses and taken corrective actions.

Conditional Accreditation

The site is accredited, but requires corrective action on some standards. Most sites receive a conditional accreditation at first and full accreditation after responding to the deficiencies by taking corrective actions. Sites are permitted to continue operating while they work on areas for improvements because there is no risk to patient safety.

Are DSM sites accredited?

All DSM sites have the required accreditation. Accreditation is an ongoing process, not a one-time requirement, so sites are always in different stages of the accreditation process. With highly trained and skilled personnel across our province, DSM is creating a patient-first environment that provides quality laboratory and diagnostic imaging services to support the health care needs of all Manitobans.

Who monitors DSM participation in MANQAP and CAP?

DSM has been participating in third party accreditation programs for years. Recently Bill 38 requires all health care facilities to be accredited by third party programs, and to make this information available to the public. DSM has its own Quality department that manages all our accreditation activities, and DSM Board of Directors has a Quality and Patient Sub-committee that oversees DSM accreditation. MANQAP of course monitors DSM participation and all reports are sent to MB Health.

Accreditation Certificates

As per Manitoba Bill 38, the following details are provided on DSM sites receiving full accreditation after November 2012.

CAP Accreditation Certificates

Health Sciences Centre 
St Boniface Hospital
Grace Hospital
Seven Oaks General Hospital
Victoria General Hospital
Brandon Regional Health Centre – Westman Lab

American Board of Forensic Toxicology Accreditation Certificate

St Boniface Hospital

MANQAP Accreditation Certificates

WINNIPEG RHA
Health Sciences Centre St Boniface Hospital Deer Lodge Centre
Histology  Histology Patient Service Centre
Cytology Cytology  Transfusion Medicine
Biochemistry Biochemistry
Hematology Urinalysis
Urinalysis Hematology
Immunology & Flow Cytometry Immunology & Flow Cytometry
Electron Microscopy Microbiology
 Transplant Immunology Transfusion Medicine
Molecular Diagnostics
 Cytogenetics
Microbiology
Transfusion Medicine
Grace Hospital Seven Oaks General Hospital Victoria General Hospital
 Laboratory  Laboratory  Laboratory
 Transfusion Medicine  Transfusion Medicine Transfusion Medicine
 Histology Histology   Histology
Misericordia Health Centre Concordia Hospital Riverview Health Centre
Laboratory  Laboratory Patient Service Centre
  Transfusion Medicine  Transfusion Medicine
Churchill  Mount Carmel
Diagnostic Imaging  Patient Service Centre
Ultrasound
Laboratory
Transfusion Medicine
SOUTHERN RHA
Altona
Boundary Trails
Carman
 Diagnostic Imaging  Diagnostic Imaging  Diagnostic Imaging
 Laboratory  Computed Tomography  Laboratory
 Transfusion Medicine Fluoroscopy  Transfusion Medicine
 Mammography – CAR
 Mammography
MRI
 Ultrasound
 Laboratory
Transfusion Medicine
Rock Lake Hospital (Crystal City) Gladstone
 Notre Dame
 Diagnostic Imaging Diagnostic Imaging  Diagnostic Imaging
 Laboratory Laboratory  Laboratory
 Transfusion Medicine  Transfusion Medicine
MacGregor Morris
 Pembina/Manitou
 Patient Service Centre  Diagnostic Imaging Patient Service Centre
 Laboratory
 Transfusion Medicine
 Portage la Prairie St Pierre-Jolys DeSalaberry
Ste Anne
Diagnostic Imaging  Diagnostic Imaging  Diagnostic Imaging
 Computed Tomography  Laboratory  Laboratory
 Fluoroscopy  Transfusion Medicine  Transfusion Medicine
Ultrasound
Laboratory
 Transfusion Medicine
Steinbach – Bethesda
Swan Lake  Vita
Diagnostic Imaging  Diagnostic Imaging Diagnostic Imaging
 Computed Tomography  Laboratory  Laboratory
 Ultrasound  Transfusion Medicine  Transfusion Medicine
Fluoroscopy
Laboratory
Transfusion Medicine
Emerson
PRAIRIE MOUNTAIN RHA
Birtle
Boissevain
Carberry
 Patient Service Centre Diagnostic Imaging  Diagnostic Imaging
Laboratory  Laboratory
Transfusion Medicine  Transfusion Medicine
 Dauphin
Deloraine
Erickson
Diagnostic Imaging  Diagnostic Imaging  Patient Service Centre
Computed Tomography  Laboratory
 Fluoroscopy  Transfusion Medicine
 Ultrasound
Laboratory
 Transfusion Medicine
 Glenboro
Grandview
 Hamiota
 Diagnostic Imaging  Diagnostic Imaging  Diagnostic Imaging
Laboratory  Laboratory
 Transfusion Medicine Transfusion Medicine Transfusion Medicine 
 Killarney Melita Minnedosa
Diagnostic Imaging  Diagnostic Imaging  Diagnostic Imaging
Ultrasound  Laboratory  Laboratory
 Laboratory  Transfusion Medicine  Transfusion Medicine
Transfusion Medicine
 Neepawa Rivers Roblin
Diagnostic Imaging Diagnostic Imaging
 Laboratory Laboratory   Ultrasound
 Transfusion Medicine  Laboratory
Transfusion Medicine
Rossburn
Russell
 Shoal Lake
Patient Service Centre  Diagnostic Imaging  Diagnostic Imaging
 Ultrasound  Laboratory
Laboratory
 Transfusion Medicine
Souris Ste Rose
 Swan River
 Diagnostic Imaging Diagnostic Imaging  Diagnostic Imaging
 Laboratory Laboratory Ultrasound
 Transfusion Medicine  Transfusion Medicine  Laboratory
 Transfusion Medicine
Treherne Virden  Wawanesa
 Diagnostic Imaging  Diagnostic Imaging  Patient Service Centre
 Laboratory  Laboratory
 Transfusion Medicine  Transfusion Medicine
Westman Lab (Brandon)
Winnipegosis  Reston
 Chemistry  Patient Service Centre
Cytology
Hematology  Baldur
Histology  Patient Service Centre
Microbiology
Transfusion Medicine
Urinalysis
INTERLAKE – EAST RHA
Arborg
Ashern  Whitemouth
 Diagnostic Imaging  Diagnostic Imaging Patient Service Centre
 Ultrasound  Laboratory
Laboratory Transfusion Medicine
  Transfusion Medicine
 Beausejour
Eriksdale  Gimli
 Diagnostic Imaging  Diagnostic Imaging  Diagnostic Imaging
 Laboratory  Ultrasound  Laboratory
 Transfusion Medicine  Laboratory Transfusion Medicine
Transfusion Medicine
Lac du Bonnet
Pinawa
 Pine Falls
 Diagnostic Imaging  Diagnostic Imaging  Diagnostic Imaging
Patient Service Centre  Laboratory  Laboratory
 Transfusion Medicine  Transfusion Medicine
Selkirk Stonewall
 Teulon
 Diagnostic Imaging  Diagnostic Imaging  Diagnostic Imaging
Computed Tomography  Laboratory  Laboratory
 Fluoroscopy  Transfusion Medicine  Transfusion Medicine
Ultrasound
 Magnetic Resonance Imaging
 Laboratory
 Transfusion Medicine
Selkirk Medical Clinic Oakbank
Patient Service Centre Patient Service Centre
NORTHERN RHA
Flin Flon
Gillam
 Diagnostic Imaging  Diagnostic Imaging
 Ultrasound   Laboratory
Laboratory Transfusion Medicine
 Transfusion Medicine
 Lynn Lake Snow Lake The Pas
Diagnostic Imaging Diagnostic Imaging  Diagnostic Imaging
 Laboratory  Laboratory  Computed Tomography
 Transfusion Medicine  Ultrasound
Laboratory
Transfusion Medicine
Thompson
 Diagnostic Imaging
 Computed Tomography
Ultrasound
Mammography – CAR
Mammography
 Laboratory
Transfusion Medicine