What to Consider When Preparing for an Urgent Care Accreditation Survey

By Barbara Newman

Whether it’s the first survey or the twentieth, the benefits of achieving accreditation greatly outweigh any challenges. Within an organization, accreditation involves all levels of staff and is easily achievable when different departments and teams come together to create consistent and effective policies and procedures for the organization as a whole. These strengthened processes, in turn, set the stage for increased efficiency and long-term quality improvement well after the survey is complete.

Organizations like an urgent center can also utilize accreditation to differentiate from competitors as well as stand out to payers and patients alike. Most accreditation standards deal with a wide scope of services and requirements, digging deep to address all areas that impact patient care. However, these standards are more than just rules to follow. They are guidelines for how to demonstrate an organization’s focus on patient safety and overall quality of care. Here are a few tips to help prepare for an accreditation survey and leverage the process to improve performance long-term.



Don’t Recreate the Wheel

When starting to prepare for an accreditation survey, look at the standards manual as more than just a dense handbook of requirements, but as an invaluable resource to guide the development and implementation of processes across an organization. The standards manual is filled with detailed information on each requirement, as well as step-by-step instructions on how to meet them, that can be especially beneficial to those going through the process for the first time.

The standards offer a template for many of the procedures required for compliance, laying the groundwork and allowing organizations to adjust to suit their needs. Organizations can buy the standards and complementary resources to establish a strong foundation of information and tools from which to build accreditation procedures and policies.

Typically, an accreditation survey is not intended to trick an organization into doing something wrong and get penalized. Rather, accreditation surveyors work collaboratively with clients assisting them to understand the intentions of a standard, thereby helping to achieve accreditation. In fact, some accrediting organizations will offer sample resources organizations can use as guides for creating their own tools, such as checklists and forms.

Benchmark and Practice

Once the standards have been reviewed and understood, policies and procedures can be developed to address discrepancies or improve quality of care. To do so, organizations must identify where key policies and procedures are missing or lacking, and test new processes to meet standards requirements.

Organizations should start by evaluating their current performance and use this as a benchmark or starting baseline. Then compare the results to standards requirements in order to pinpoint where improvements or additions must be made. After adjusting procedures, measure performance again and compare to the benchmarking results. This will form the basis of ongoing quality improvement initiatives that can be customized for each department or team. Repeat this process at regular intervals to gauge improvements in performance as well as create opportunities for innovative changes.

The initial benchmarking can also help organizations determine how much time they will need to make the necessary changes before the accreditation survey, offering a timeline to enhance planning and organizing.  After quality improvements have been made, organizations can host a mock survey to help staff become familiar with the actual accreditation survey process and put their best practices to the test. These exercises are imperative when changes or additions are made to standards, allowing organizations to more nimbly tweak their benchmarking and procedures to meet new requirements.

Integrate Staff from the Start

Accreditation is an exercise in teamwork, encouraging all departments to come together to learn about the standards, collaborate on new processes and implement best practices. During an accreditation survey, all levels of staff are involved and called upon to demonstrate their knowledge in putting the standards into practice.

To achieve this level of understanding and consistency, staff must be integrated into the accreditation process from the start – learning not only the requirements for each standard but the intentions behind them as well. When staff understands the importance of accreditation standards and the impact they can have on patient safety and outcomes, it is easier to obtain buy-in and cooperation throughout the preparation process. In addition, keeping staff informed throughout will make it easier to manage any changes to standards requirements, as well as ensure quality improvement is ongoing.

Continue Policies Beyond

In preparing for an accreditation survey, organizations discover areas of improvement, develop new policies to correct discrepancies, and develop a greater understanding and appreciation for the purpose behind the standards. This, however, should not end when the survey is complete.

All the education, benchmarking, practicing and communication should continue well beyond the survey experience and become ingrained in the daily operations of the organization. Through collaboration, teams can work together to improve the delivery of care with innovation and consistency.

When efforts to improve remain ongoing, preparing for the next accreditation survey three years later will no longer seem like an insurmountable task, but rather an opportunity to demonstrate all the amazing work the organization does for patients each day. By making accreditation a constant exercise in benchmarking and quality improvement, organizations are guaranteeing that patient safety and quality of care remain top priorities.

Ask Questions

There are several steps to preparing for an accreditation survey that focus on education, communication and consistency. While the task may seem daunting, with the right foundations in place and multidisciplinary teamwork, accreditation is certainly achievable.

Teaming up with an accrediting organization that offers valuable insight and tools is key to understanding the intentions behind the standards and developing procedures to not only meet the requirements but establish ongoing quality improvement for future ROI.  Preparing for accreditation helps urgent care centers develop and implement consistent processes, making every required standard a routine practice leading to unanticipated efficiencies.

Barbara Newman is a Practice Management Content Coordinator 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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