5 Tips to prepare for an urgent care accreditation survey

Accreditation is more than just a test of a facility’s ability to follow specific rules.

Preparing for an accreditation survey provides healthcare organizations with an opportunity to improve and expand their policies and procedures to strengthen the quality of care delivered. By meeting industry-leading standards, healthcare organizations can demonstrate their commitment to patient safety, quality improvement and value-based services.

When an urgent care center achieves accreditation, they are better able to distinguish themselves from competitors for patients and payers - many of which are requiring urgent care centers to get accredited to remain in network. And while there is work involved, achieving accreditation for an urgent care facility is not an insurmountable task. In fact, when all the necessary steps are taken to prepare, accreditation is a reachable goal for most organizations.

1. Allow Enough Time to Prepare
A common mistake an urgent care facility can make when getting ready for an accreditation survey is to not dedicate enough time to get ready. The centers that rush their preparations tend to struggle the most. Many groups will wisely allow at least four months to prepare for an accreditation survey, ensuring there is enough time to review the standards, understand their intent and train staff on how best to implement them into daily practice.

This rule applies to both small and large organizations. Large organizations often divide up the standards to different departments, but everyone must work together and be on the same page to ensure a smooth survey. Small organizations may only have one or two employees in charge of accreditation preparation, and therefore will likely need more time to fully prepare.

Whether the urgent care organization is large, small or somewhere in between, it takes time to review current policies and procedures, understand the standards and measure performance. Organizations must also allow time to adjust practices and make improvements to avoid deficiencies, as well as gather and submit data when needed.

2. Engage with Staff at All Levels
Another way to simplify the accreditation survey preparation is by including staff at all levels within the organization – from leadership to part-time support staff. Being involved in the preparations means more than writing policies and assigning to-do lists before the survey. Engaged staff will learn about the standards, understand their intention and apply new practices in their day-to-day care to ensure compliance and quality improvement.

This is vital, as the actual accreditation survey will involve more than just the executive team, calling on the staff on the front lines to demonstrate their understanding of the standards firsthand. Preparing for an accreditation survey is a wonderful opportunity to share ideas and best practices with colleagues as you develop new procedures for success. The faster everyone is up-to-speed, the easier it will be to make adjustments prior to the survey.

3. Strengthen the Communications Cascade
When collaborating with staff in all departments and levels, it is important to maintain strong lines of communication. This ensures all questions or concerns are addressed as soon as possible, and everyone is operating under the same policies and procedures. Consistency is key when it comes to patient safety and quality improvement, as any inconsistencies will likely be noticed during an accreditation survey.

That is why teams should avoid working in silos and rather come together to see the big picture and realize their important roles within the larger organization. This requires constant, open communication across departments to ensure a steady flow of information and feedback.

In addition, strong communication with your accreditation provider is valuable to long-term success. Look for an accrediting organization that offers educational resources to help prepare for the survey such as instructional literature, webinars, workshops and expert hotlines. For example, the Urgent Care Association (UCA) offers hands-on workshops that include mock surveys and in-depth discussions on standard requirements.

Get comfortable communicating with your accrediting organization, ask questions about standard changes or updates, and seek advice when your organization seems to have hit a roadblock. The accrediting organization should have the same goal as the urgent care organization – accreditation. This means the experience leading up to, during and after the accreditation is a collaborative one, focused on learning and improvement, not testing and punishment.

4. Create an HR Pipeline
Some urgent care centers may not have a dedicated human resources department to oversee key documents (whether digital or paper) that are reviewed during an accreditation survey. As part of the accreditation survey process, policies and procedures should be put into place to prevent common oversights or incomplete files.

To keep documents organized and flowing smoothly through all the appropriate channels, urgent care staff can create checklists for different standards to ensure all requirements are met. These checklists can be quite detailed and include all tasks and responsibilities broken down by department, as well as a recommended timeline for meeting key deadlines. Each year the checklists and procedures can be reviewed to determine if they are still in line with the standards, or if any key learnings can be applied to improve performance.

A slim or nonexistent HR department does not mean it will be more difficult for that urgent care center to achieve accreditation. However, someone needs to be responsible for gathering the information. In fact, accreditation is quite achievable once staff members understand the standards and identify the right procedures needed to fill any gaps.

5. Commit to Quality Improvement
Quality improvement is a key component to any accreditation program, ensuring healthcare providers are constantly tracking and measuring their performance to identify areas where adjustments can be made for improved outcomes.

To start, organizations should measure their current operations and performance for a benchmark and compare the results to the standards. This will assist teams in understanding where improvements should be made and how much work must be done to prepare for the survey. When developing and testing new policies and procedures to improve patient safety and value-based services, continue to gather data and track progress for long-term benchmarking.

Quality Improvement programs are a vital component of not only accreditation success but strong patient outcomes as well. Persistent challenges in healthcare are successfully combatted when all providers and staff make it a priority to improve in areas of weakness or inefficiency. Antibiotic stewardship, for example, is a major concern for the entire healthcare industry. As a result, many quality improvement initiatives are focused specifically on improving antibiotic stewardship. In fact, the UCA has added antibiotic stewardship quality improvement to its 2019 standards requiring all urgent care centers demonstrate their ongoing efforts to counter antimicrobial resistance and improve patient safety.

Organizations that adopt quality improvement into their day-to-day tasks can approach an accreditation survey with significant data demonstrating how performance is monitored and what adjustments have been made over time to boost outcomes or efficiency. Likewise, with the policies already in place, teams will not be scrambling at the last minute to gather data and implement a quality improvement initiative right before a survey. When quality improvement is no longer seen as an accreditation standard, but rather a key component to high-quality care, it seamlessly becomes ingrained in how an urgent care center operates and further simplifies the accreditation process.

Beyond the Survey
When preparing for an accreditation survey, urgent care centers have an opportunity to develop and implement consistent processes across all sites, making every required standard a routine practice that leads to unanticipated efficiencies. Policies and procedures provide clarity, and achieving accreditation requires teamwork and generates a sense of pride and accomplishment.

Involving staff in the values of quality and safety will ultimately result in more engaged, patient-focused employees, as well as long-term commitments to ongoing quality improvement, learning and growth. Acing an accreditation survey is just one benefit of adopting strong policies and procedures dedicated to patient safety and value-based services.

About the Author
Barbara Newman is an Accreditation Surveyor for the Urgent Care Association (UCA) which is expanding the scope of its offerings to include new care providers and technologies that are critical to on-demand care. Barbara serves on the Certification/Accreditation Committee reviewing the Certification and Accreditation standards of practice in urgent care. She is also the Practice Management Content Coordinator for UCA Conventions and Conferences and serves as the Chair of the Practice Management Content Committee. In this role, she is responsible for vetting and advising on all practice management-related content for UCA presentations to ensure quality content is delivered. Barbara graduated from the University of New Orleans with a BA in Sociology.

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