A staged approach to accreditation preparation
1. Gap Analysis
Healthsmith likes to begin each accreditation preparation with a gap analysis. This is typically conducted on-site and includes a review of current documents and practices. The Consultant will review current policies, files, reports, and materials with key staff and gain a thorough understanding of current operational practices. The Consultant will deliver and review a written, detailed gap analysis, evaluating the organization against all applicable requirements.
2. Evidence Production
Based upon the results of the Gap Analysis, the Healthsmith Consultant will develop a project plan and inventory that outlines all required evidence that needs to be revised or created for presentation to the accrediting body. Healthsmith has designed customizable tools and document templates that have been tested and approved to meet the accreditation and industry standards. Throughout this preparation stage the consultant will create all necessary policies, procedures and program descriptions and review reports, letter templates and other materials created by the organization to ensure they comply with the applicable regulations and standards. The Consultant will routinely meet with key staff in the organization to review all draft documents and ensure content is accurate, compliant and completed timely.
3. Application Review and Completion
If needed, the Healthsmith Consultant can provide an overview of the accreditation process and offer helpful hints to ease the application completion process. Once all documents are completed, the Consultant can review the application in its entirety to ensure accuracy. This stage also includes the Consultant’s coordination of conferences and responses to all requests for information and re-submission of any missing or insufficient documentation that is noted by the accrediting body. This may also include the Consultant’s presence on conference calls to gain clarity or negotiate citations directly with the accreditor.
4. Staff Training
It is typically an expectation that all staff receive training on the accreditation standards as applicable to their organizational role. Additionally, as part of the on-site review key positions as well as randomly selected staff may be interviewed by the auditors. Staffs’ understanding of accreditation is crucial to a successful review. The Healthsmith Consultant will create training curriculum as well as conduct training. This training can be conducted on-site or via web meeting and can be offered in multiple repeat sessions to ensure all staff receives the appropriate education with minimal interruption to operations.
5. On-Site Preparation
Once the application has been submitted and accepted, the Healthsmith Consultant will work with the organization to advise and review all necessary materials and preparations for the on-site review. The Consultant will develop an on-site preparation project plan and continue to meet with key leadership routinely via web-meeting to ensure appropriate documents are ready and staff is prepared by the assigned on-site review date. This on-site project plan is designed using the actual accrediting body's agenda and required materials. Once this stage is complete the organization will be prepared for their Mock Audit.
6. Mock Audit
Prior to the scheduled on-site visit, the Healthsmith Consultant will conduct a mock on-site review. This review will follow the accrediting body's on-site agenda, including review of materials, files and interviews and observations of staff. The last day of this on-site review will consist of a presentation of any findings and recommendations for improvement.
7. On-Site Support
Although Consultants cannot take a lead role in the on-site accreditation review, it has proven to be helpful to have the Healthsmith Consultant on-site to provide guidance and support throughout the review day. The Consultant can address questions that arise, help determine and provide any requested evidence, provide guidance to staff, debrief with those who have been interviewed to determine any potential issues and advise staff on direction for upcoming interviews and file reviews.