Frequently Asked Questions About Accreditation
This area addresses Accreditation questions posed by UCAOA members. E-mail staff if you have any additional questions.
Process
Step 1 – Review the Handbook (download at right) and Standards and Assess your Compliance
Start work to complete any needed changes by the time of your on-site accreditation survey.
Step 2 - Apply for Accreditation
Step 3 – Schedule your on-site survey date
Work with your Account Representative to choose a survey date.
Step 4 - After your Survey
You’ll be given a copy of the surveyor’s final report immediately after your survey.
Step 5 - Between Surveys
Work with Joint Commission tools to regularly review your performance.
Background Information
I thought The Joint Commission was mainly for hospitals?
Actually, only 26% of The Joint Commission work is in hospitals: read an article by Dr. Mark Chassin, the Joint Commission's new President, from the June 2008 Journal of Family Practice on how The Joint Commission works in smaller settings, like ambulatory care.
What does this all mean and what's coming?
This collaboration means that urgent care centers will have a nationally-recognized accreditation that is also tailored to urgent care.
While centers can go immediately to The Joint Commission to pursue ambulatory accreditation, UCAOA is working with TJC to develop urgent care specific materials:
How is UCAOA Providing Input to The Joint Commission?
UCAOA members and staff are involved in several ongoing committees and projects with The Joint Commission:
- Representatives on the Professional and Technical Advisory Committee for Ambulatory Care
- Identifying candidates for surveyors for urgent care centers
- Providing technical assistance to the Standards Interpretation Group on urgent care issues
- Providing input during field reviews of standards in development
- Development of resources listed above - applicability grids, manuals, and process guides
How to Get Started, Fees, Process, etc.
I'm ready to look into this seriously, what's the first step?
The first step is to contact the Joint Commission and let them know you are ready, that will start the process. This 3 page overview has a summary of the entire experience.
How much does it cost?
It depends on how many patients you see (which leads to how many "patient tracers" are needed...more on this below) and how many centers you have. Use the Joint Commission Accreditation Fees Worksheet to estimate your costs. Only a portion of the fees are paid up front. Tthe remainder is paid over the duration of your accreditation.
What is the survey like? Who are the surveyors?
The following is excerpted from an August 2008 interview with Michael Kulczycki, Executive Director of Ambulatory Care Accreditation at the Joint Commission (view the full article in the Journal of Urgent Care Medicine):
The survey process is “open book.” There are no secrets. The standards and elements of performance (EPs) which define compliance with the standards are all provided “up front.” They are the same standards and EPs the surveyors use in the evaluation. Organizations also receive a detailed agenda of the survey visit that outlines, hour by hour, the purpose of each time slot on the agenda, which staff will be involved, and any additional resources the center should have available, so they know what to expect.
“Patient tracers” are the main component of the survey process, accounting for 60% of the survey time. The surveyor selects incoming patient charts as a “roadmap” through the center, then observes those patients (with their permission) throughout their visits. The surveyor uses those observations to help evaluate the organization. During the patient tracers, surveyors also talk to staff about their role (e.g., intake, delivery of care, education of patient, discharge, etc.), but do not focus on the details of any one standard. In many cases, these interactions help to “connect the dots” for staff as to why they need to use two patient identifiers, etc.
Surveyors are not looking, despite “urban legend,” for dust bunnies in the corner of the rooms. They are simply using the evaluation tools (patient tracers, dialogue with staff, discussions with patients) to assess compliance with applicable standards, and providing suggestions for achieving future compliance.
The surveyors themselves are all ambulatory care professionals with a minimum of five years of ambulatory practice experience. More than three quarters of the surveyors are physicians, and they are all employees, dedicating one quarter or one-half of their time only to Joint Commission surveys. This means they typically visit 50 to 100 ambulatory centers each year, and can bring those “good practices” they see across the country to your centers as part of the survey process.
