BHB Posts Hospital-Wide Accreditation Report to Website

Preston Swan, Vice President, Quality & Risk, introduces the report:

A key metric for patient safety at BHB is hospital-wide accreditation. But what is accreditation? It is a survey that measures whether a hospital meets set patient safety standards. In its 2015 accreditation survey with Accreditation Canada, BHB was measured against 3,209 applicable standards.

Here’s an example of a patient safety standard: BHB staff must check two patient identifiers before any interaction, treatment, medication or surgery. This simple action prevents wrong surgeries, medication errors and improper testing. This standard is a ‘Required Organizational practice’ for Accreditation Canada. It is also a ‘Red Rule’ at BHB – no exceptions allowed. Other standards cover proper hand hygiene, safety checklists and advance directives, clinical procedures and patient education, as well as good governance and community collaboration.

BHB is measured against the same standards as 1,108 Canadian hospitals. The ability to be measured against Canada’s home standards is a major benefit of being accredited by Accreditation Canada.

So how is the survey carried out? In May 2015, four healthcare experts were sent by Accreditation Canada to spend a week at BHB. They went into departments across BHB, including King Edward VII Memorial Hospital, the Mid-Atlantic Wellness Institute and the Lamb Foggo Urgent Care Centre. The Surveyors pulled medical records and interviewed patients, staff, physicians and external stakeholders. They watched patient interactions and they checked that we recorded our activities and interactions appropriately.

The table below has a summary of BHB’s 2015 performance, where 2,999 standards out of 3,209 applicable standards (93%) were met. Non applicable (N/A) standards include all those that relate to services BHB does not currently provide. BHB’s survey result earned it accreditation once more! To maintain its accreditation status, BHB continues to work with Accreditation Canada on unmet standards and Required Organizational Practices. Further evidence of improvement has to be sent to Accreditation Canada in October 2016, new and updated standards will be applied each year, and the next survey is already planned for 2019.

BHB’s accreditation survey reports have been made public since 2008, and can be found on our website. In the table below you can also see how many standards we have been measured against and how many we achieved for the last three surveys, including this year. In 2015, we were measured against 646 more standards than in 2011 and 1,707 more standards than in 2008. The bar is always getting higher and this is a positive drive for patient safety in Bermuda.

Accreditation surveys provide snapshots in time on our patient safety practices. They are guides and measures that help us on our journey to provide a safe, high quality service.

BHB staff members are expected to live all the standards, every day. BHB has two Accreditation and Quality Compliance Managers who educate staff and monitor adherence to standards in between surveys, but the responsibility is on the shoulders of every member of staff to follow these and other quality standards in every patient interaction.

Finally, alongside hospital-wide accreditation, BHB has specialist accreditations with the American College of Radiation for Diagnostic Imaging and is a designated Breast Imaging Centre of Excellence. BHB also has accreditation with Joint Commission International for the Laboratory and with the Commission on Accreditation of Rehabilitation Facilities (CARF) for our substance abuse service at Turning Point.

More information about Accreditation Canada can be found at

2015 Accreditation Report

June 2015 Decision Letter

November 2015 Decision Letter

November 2016 Decision Letter

Comparison Table 2008-2011-2015


2024 (25)
2023 (30)
2022 (58)
2021 (67)
2020 (66)
2019 (45)
2018 (35)
2017 (40)
2016 (47)
2015 (22)
2014 (45)
2013 (36)
2012 (37)
2011 (43)
2010 (44)
2009 (56)
2008 (31)
2007 (32)
2006 (39)
2005 (27)
2004 (23)