Achieving accreditation is a big step for any medical organization and it can take time to meet an accreditor’s standards. Preparation is the key to a successful accreditation outcome. Michon Villanueva, assistant director of accreditation services with the Accreditation Association for Ambulatory Health Care (AAAHC), discusses four critical aspects of accreditation every organization should know before beginning the process.
1. Document your policies. When the surveyors arrive, they will ask to see the organization's documentation regarding policies and processes. An organization may have unwritten policies or processes which organization members follow from tradition or verbal instruction, says Ms. Villanueva. In other instances, policies are recorded but not updated. Organizations are encouraged to review and record policies and processes, ensure they are up to date to and be able to demonstrate they are followed correctly. This will also ensure consistency.
"In my experience, it's typical that organizations haven't reviewed their policies on a regularly-scheduled basis," says Ms. Villanueva. "There has to be a mechanism to ascertain what the process is and that the organization is doing what they say they're doing." Policies and processes must be reviewed and updated regularly as technology and practice standards change, and as new equipment or services are made available. These updates are easier to track with written documentation.
2. Address risk-management. During an accreditation survey, surveyors are responsible for reviewing and documenting how the organization provides care in a safe and sanitary environment. It is critical for the organization to develop processes to ensure it can provide consistent, high quality care for the various types of procedures it performs. The organization should define their clinical procedures and review or create policies for risk management in their setting. Additionally, organizations should keep current with standards relating to infection prevention.
3. Keep organization members updated. In order to achieve accreditation, an organization must demonstrate that all of their members understand their policies and are up-to-date on their specific practices and guidelines. Ms. Villanueva suggests an organization involve its members from all levels with the entire accreditation process. "Accreditation has to be a company goal or a practice goal. Working toward accreditation is a ‘team sport’," says Ms. Villanueva. "There's the ability for an organization to use the work involved in accreditation as a tool to motivate its staff to achieve the next higher level of quality."
4. Attend accreditation seminars. For organizations planning on seeking accreditation for the first time, attending seminars held by its chosen accreditor can be particularly helpful in detailing the necessary steps for achieving accreditation. "These seminars are in-depth, review all the standards and the survey process itself and the seminars are taught mostly by surveyors," says Villanueva. "There are interactive breakout sessions where small groups of organizations get together to discuss accreditation standards and to gain input on successful implementation."
Additionally, attendees receive the tools needed to prepare for an AAAHC survey, such as the AAAHC Handbook for Ambulatory Health Care. This Handbook includes the AAAHC standards and its survey policies and is a valuable tool for organizations to conduct a pre-survey self-assessment. Going through such a self-assessment creates awareness for the organization of its compliance with the standards applicable to its services and helps create a more efficient implementation process for organizational changes and improvements.
Learn more about AAAHC.
Read more coverage on accreditation:
- 8 Best Practices for Maintaining Accreditation
- AAAHC Announces Changes to the 2010 Handbook
- 3 Quick Tips to Better Meet Accreditation Standards
1. Document your policies. When the surveyors arrive, they will ask to see the organization's documentation regarding policies and processes. An organization may have unwritten policies or processes which organization members follow from tradition or verbal instruction, says Ms. Villanueva. In other instances, policies are recorded but not updated. Organizations are encouraged to review and record policies and processes, ensure they are up to date to and be able to demonstrate they are followed correctly. This will also ensure consistency.
"In my experience, it's typical that organizations haven't reviewed their policies on a regularly-scheduled basis," says Ms. Villanueva. "There has to be a mechanism to ascertain what the process is and that the organization is doing what they say they're doing." Policies and processes must be reviewed and updated regularly as technology and practice standards change, and as new equipment or services are made available. These updates are easier to track with written documentation.
2. Address risk-management. During an accreditation survey, surveyors are responsible for reviewing and documenting how the organization provides care in a safe and sanitary environment. It is critical for the organization to develop processes to ensure it can provide consistent, high quality care for the various types of procedures it performs. The organization should define their clinical procedures and review or create policies for risk management in their setting. Additionally, organizations should keep current with standards relating to infection prevention.
3. Keep organization members updated. In order to achieve accreditation, an organization must demonstrate that all of their members understand their policies and are up-to-date on their specific practices and guidelines. Ms. Villanueva suggests an organization involve its members from all levels with the entire accreditation process. "Accreditation has to be a company goal or a practice goal. Working toward accreditation is a ‘team sport’," says Ms. Villanueva. "There's the ability for an organization to use the work involved in accreditation as a tool to motivate its staff to achieve the next higher level of quality."
4. Attend accreditation seminars. For organizations planning on seeking accreditation for the first time, attending seminars held by its chosen accreditor can be particularly helpful in detailing the necessary steps for achieving accreditation. "These seminars are in-depth, review all the standards and the survey process itself and the seminars are taught mostly by surveyors," says Villanueva. "There are interactive breakout sessions where small groups of organizations get together to discuss accreditation standards and to gain input on successful implementation."
Additionally, attendees receive the tools needed to prepare for an AAAHC survey, such as the AAAHC Handbook for Ambulatory Health Care. This Handbook includes the AAAHC standards and its survey policies and is a valuable tool for organizations to conduct a pre-survey self-assessment. Going through such a self-assessment creates awareness for the organization of its compliance with the standards applicable to its services and helps create a more efficient implementation process for organizational changes and improvements.
Learn more about AAAHC.
Read more coverage on accreditation:
- 8 Best Practices for Maintaining Accreditation
- AAAHC Announces Changes to the 2010 Handbook
- 3 Quick Tips to Better Meet Accreditation Standards