Am I able to apply before I open my center?
Yes. UCA offers an Early Accreditation option. Organizations may seek accreditation up to 6 months prior to opening their first center (startup organization). An attestation is available for a senior level officer to complete, attesting that the new location will meet the standards for accreditation and certification at the time it opens. Additionally, the organization must submit the appropriate application and associated fees 45-60 days prior to opening. The organization is to be survey-ready within the first 60 days after opening. If the survey has not been scheduled and the organization desires to withdraw the application, the Accreditation status will be lost, and the organization will forfeit the full amount paid. If opening is delayed and surveyor travel has already been scheduled (airfare booked), any travel related change fee would be covered by the organization.
How do I obtain the UCA accreditation standards and preparation manual?
The UCA Accreditation Standards and Preparation Manual is available through UCA’s online store and is forwarded to applicants as soon as their application is processed. This manual consists of standards and required expectations as well as potential success demonstrators. Should an organization choose to purchase the UCA Accreditation Standards and Preparation Manual prior to applying for accreditation, the purchase price will be subtracted from the accreditation application fee if the organization elects to proceed with the process and pays for accreditation application fee within six (6) months of the purchase. NOTE: Organizations may be asked to provide a valid paid invoice for the manual at the time of application so please retain your receipt.
What is a standard?
- A standard is a practice goal for a field or industry that is widely recognized or employed as a model of excellence. A standard is not a regulation, although some may require that the organization adhere to a state or federal regulation. While a regulation is generally set as a minimum requirement for a field, a standard typically represents a higher level of practice.
- UCA standards include Governance, Human Resources, Patient Care Processes, Quality Improvement, Physical Environment, Health Record Management and Patient Privacy/Rights/Responsibilities standards as well as the UCA certification criteria.
- Standards apply to all organizations regardless of size or model of operation.
- How a standard is implemented is defined by the organization.
- The standards represent a set of practices that collectively support strong organizational performance and positive service delivery outcomes.
What is the difference between a standard, an expectation, and a success demonstrator?
- A standard is a requirement that must be demonstrated to prove compliance.
- An expectation is also a requirement that must be demonstrated to prove compliance with a standard. Expectations provide greater detail of the standard.
- A success demonstrator is a suggestion of how to demonstrate evidence of an accomplishment of an aim or purpose (i.e., accomplishment of a standard and its expectations). UCA does not dictate to organizations how each standard and expectation are implemented but will assess the effectiveness of the processes or actions currently implemented to demonstrate compliance. While free to adopt the suggestions/guidelines listed, organizations are encouraged to explore their own methods to meet the standards and expectations.
What happens during a survey?
- The UCA survey experience is both facilitative and collaborative. The surveyor provides the organization the opportunity to demonstrate how it implements the standards.
- The survey is perhaps the most important step in the UCA Accreditation process because this is when a surveyor assesses the way you have implemented/interpreted the UCA standards and expectations.
- The surveyor will also evaluate the center’s scope of care to ensure it meets the criteria established to distinguish it as a Certified Urgent Care site. It is important to note that an applicant MUST meet all Certification requirements as outlined in the UCA Accreditation Standards manual at the time of the survey. This is a pass/fail requirement. If the applicant does not demonstrate during the survey visit that it meets the Certification requirements as previously attested in its application, the surveyor has the authority to terminate the survey process. Application fees are forfeited, and the application is closed. The organization must submit a new application with application fee once it has demonstrated that it now meets the Certification requirements via a Certified Urgent Care application for each center.
- On an initial survey, it is not necessary to demonstrate a history of compliance within the organization for most standards. The expectation is that a process has been put in place to demonstrate compliance with the standard. If a history is not evident but a process or policy meets the criteria, it will be assumed that the center has met the standard.
- If a process is new to the organization on the initial visit, there will be follow up on the next survey to ensure that what was observed and represented is in place has indeed been implemented.
The Pre-Conference is the formal "kickoff" of the survey. Organizations may wish to include key leadership and staff who have been involved in preparing for the survey. During this part of the process, the surveyor will review what can be expected during the survey, including follow-up activities and answer any questions about the process itself.
Interviews and Observations
When a site visit occurs, the surveyor will tour the organization's centers to observe the safety, quality, and maintenance of the facility. During these tours, the surveyor will also observe staff/patient interactions. Discussions are conducted with staff to confirm an awareness with the processes and policies of the organization. The surveyor will also observe patient intake and triage processes during the site visit.
The Post-Conference is intended to provide the organization with some initial feedback and to assure all administration, board members, executive and management staff and key staff members understand what to expect going forward. This also allows an organization to ask questions and bring closure to this phase of the process.
Who are the surveyors and what is their role?
UCA prides itself on the caliber of its surveyors as an essential component of the UCA Accreditation process. They have made a commitment to ensure integrity throughout the survey process. UCA surveyors are trained no less than annually on UCA processes, and standards as well as privacy regulations. Each surveyor dedicates many hours to each assigned survey. Surveyors familiarize themselves with each organization prior to the survey and have responsibilities until all survey activities conclude.
UCA surveyors may vary over time but are one or more of the following:
- Registered Nurses familiar with health care accreditation processes.
- Physicians and Advanced Practice Practitioners (APPs) familiar with health care accreditation processes.
- Practice Administrators in the Urgent Care field.
- Health Care Professionals in the Urgent Care field.
- Recently retired senior staff members from Urgent Care organizations who continue to maintain an active role in the field.
Surveyors have experience with the accreditation and survey process and have demonstrated a true commitment to the purpose and goals of UCA Accreditation.
How should we prepare for our site visit?
Although senior management and staff are involved in all aspects of the accreditation efforts, the survey is the primary opportunity for staff at all levels in the organization to understand the gravity of their involvement and participation preparation and overall accreditation success. There are several things that you should consider leading up to your survey:
- Prepare staff in advance. Meet with the staff as you did when you first decided to embark on this journey. Reinforce how important their participation is and how confident you are this will be a successful endeavor. Make sure they know who will be involved and the standards in their area that may be discussed.
- Consider conducting an internal mock survey to create comfort with the survey process and to familiarize staff with the survey expectation
- Review the Certification Checklist to ensure that your site meets the criteria established for scope and patient access.
- Plan for the Pre- and Post-Conference and send invitations to any staff you would like to participate in these meetings.
- When a surveyor is on site, identify a room for the surveyor to use offering privacy and minimal disruption. Be technically prepared (computer and web access ready) to demonstrate compliance with pre-identified policies or criteria in electronic format. Surveyors will never request medical records or other protected health information (PHI) be made available for downloading onto another computer. Documents containing PHI will only be reviewed via screen sharing or while on site at the organization. Ensure human resource records, credentialing and privileging records and QI documentation are available. Also, be sure to designate a staff person to facilitate all interactions with the surveyor who is adept at accessing records and other important documents.
- Prepare staff at all organization locations of the surveyors visit when coming on site.
- Develop a plan to reward staff for their participation at the conclusion of the survey.
What happens after our survey is complete?
Immediately following the completion of a survey, your organization should do the following:
- Pause for a moment to celebrate your organization's achievements. The completion of the survey is a significant milestone in the process. For this reason, it is important to recognize all the people who have contributed to the accreditation process up to this point.
- Evaluate how the survey process went and ask yourselves, "In what areas of the standards did we do well? Where did the surveyor identify areas for improvement?" If your organization is aware of needed improvements, you are encouraged t to concentrate on these areas. There is no reason to await the UCA survey response letter if you are aware of an improvement / compliance opportunity.
The UCA surveyor will send completed documentation with comments to the UCA Accreditation Committee. UCA then begins preparing your survey response. This report identifies only those standards that require a response and/or improvement/action step(s). Some areas may also be noted that were rectified by the organization during the survey itself or are simply recommendations based on findings. Those areas may be listed but will also indicate that no response is required.
Within forty-five (45) business days from the site visit, the organization will receive a copy of your report. It will be accompanied by a cover letter and instructions for how to prepare the response in electronic format. You will then have sixty (60) days to submit any required follow-up action items to the committee for review.
What happens if we cancel any part of the survey process?
An organization who voluntarily withdraw from the accreditation process at any time prior to scheduling a survey will forfeit its full application fee. Forfeited funds may not be applied to any other UCA events, products, membership, education, or materials. Canceling a confirmed survey date will result in forfeiture of the entire application costs and the applicant will be responsible for any non-refundable expenses including travel arrangements already made. Forfeited funds may not be applied to any other UCA events, products, membership, education, or materials.
What are the levels of accreditation awarded?
After the Committee reviews the survey findings and any subsequent action items submitted by the applicant, Accreditation plus Certification are awarded as follows:
Accreditation or Reaccreditation: The Accreditation Committee awards accreditation or reaccreditation to an organization for a period of three years when: 1.) The applying organization meets the requirements of UCA Standards and Expectations following the survey; 2.) there is no cause for concern about implementation of/or continuing performance with UCA standards; and 3.) the organization meets the scope of services criteria established to be recognized as a Certified Urgent Care Center.
Pending: When the Accreditation Committee has questions about an organization's implementation of/continuing performance with a standard that may require additional documentation/information for approval, they have the discretion to place the organization on pending status and to request this documentation. Full accreditation is not granted until the organization submits this documentation and the Committee finds it now meets the standard.
Provisional: The Accreditation Committee grants accreditation to an organization with the stipulation that the organization must submit additional documentation of completed compliance within a designated time frame. If the organization does not submit the requested documentation, its accreditation designation is revoked. Additionally, provisional status may be awarded if a virtual survey has been successfully completed but an on-site visit is pending.
Right to Resurvey: The Accreditation Committee reserves the right to resurvey the organization depending on the initial survey findings; it is the responsibility of the applying organization to submit a new application and fees for this resurvey.
Denial: The Accreditation Committee reserves the right to deny an organization accreditation status if: 1) a surveyor determines during a site visit that the organization has failed to meet the minimum standards and there is no opportunity for corrective action; 2) a surveyor determines during a site visit that the organization blatantly compromised patient quality or safety; or 3) an organization fails to respond to the Accreditation Committee’s request for additional documentation/information within the appropriate time frame.
An organization has the right to appeal any Accreditation Committee’s decision.
What happens after we achieve accreditation?
Following the successful completion of the accreditation process, you will receive the following:
- An email communication stating that your organization has achieved dual accreditation and certification. This is sent within seven (7) business days after the final decision is made.
- A packet that contains, among other things, a formal notification letter stating that your organization has been accredited and certified, your accreditation/ certification expiration date and a list of services that were reviewed.
- Promotional tools to help convey your monumental achievement to your staff, community, and other stakeholders. Tools will include a sample press release and other suggested actions to take. Additionally, UCA will promote your successful dual accreditation/ certification distinction on its website.
- Certificates reflecting your achievement of UCA Accreditation and Certification as well as other distinctions you may have elected to pursue such as Antibiotic Stewardship Commendation
What happens if we open a new site(s) in between our accreditation cycle?
Newly opened centers during an accredited organization cycle period may consider that clinic to be accredited upon execution and submission of an written attestation that the clinic operates under the same standards and policies/procedures as the surveyed accredited sites AND once newly opened sites submits verification that it meets and is awarded UCA certification status. Accreditation & Certification Certificates will be available for the newly opened center once the attestation statement is received. The accreditation status for the new site will expire commensurate to the dates of the other locations in the organizations included in the previous survey process. A $540 new location fee will be assessed per center added by attestation. This cost will be prorated according to where an organization is at in their survey term. Organizations will pay 100% of the new site price if they were accredited with-in 12 months or less, 2/3 of the new site price if they were accredited within-in 1 year to 24 months, and 1/3 of the new site price if they were accredited if within the final 12 months of their accreditation approval term. Therefore, a new site attested to in the third year of an accreditation cycle would pay $180 and subsequently be re-accredited in alignment with the other organization’s sites.
What happens if we acquire or merge with an organization with site(s) that are already open during our accreditation cycle?
Accredited organizations who acquire or merge with another organization may consider those centers accredited upon execution and submission of an attestation statement acknowledging that the center will be in compliance with UCA standards/expectations and policies/procedures as the surveyed accredited sites within 120 days of the acquisition or merger. Accreditation and Certification certificates will be available for the newly acquired or merged centers once the attestation statement is received and the invoice for new sites paid in accordance with where the organization is in its 36-month accreditation cycle. The accreditation status for the new center(s) will expire concomitant to the expiration date of the existing accredited organization.
We are accredited by another accrediting organization but want to convert to UCA accreditation. Our accreditation expires soon. Is there an interim accreditation option that allows us to prepare?
It is possible that organizations accredited by another recognized accrediting body may receive additional time to prepare for their UCA survey up to 6 months following their expiration date. The organization will receive a certificate of accreditation for the 6 months. A survey must take place during this 6-month period allowing enough time for the organization to not only prepare for the survey, but to respond to the survey response and allow the committee time for review of the response. A 10% administrative fee (or the cost of the survey based on organization size) will be assessed at the time of application. Contact UCA at firstname.lastname@example.org to find out more information about qualification and processes related to this program.
How do we maintain our UCA accreditation?
Accredited organizations should continually monitor themselves and review their processes for meeting standard requirements throughout the accreditation period. Continuous involvement by administration/ management/ staff/ medical providers assures engagement in the process and successful reaccreditation by the organization. Should there be a change in status, ownership, or scope, your organization must notify UCA within 30 days of the change.
Organizations are invited to participate in an Annual Compliance Review (ACR) program. This program is optional, but strongly encouraged. The goal of this program is to help organizations stay on track maintaining documentation demonstrating compliance with accreditation standards/expectations. It is offered on annual basis during the 3-year period between an organizations site survey and re-survey. It will also provide the opportunity for organizations to ask questions related to any new or revised standards. The program offers a one-hour telephone call will an experienced UCA surveyor and the organization’s leadership designee(s). It allows the organization to participate in creating the agenda so the surveyor covers what the organization’s team would like to review. For more information about the Annual Compliance Review (ACR) please contact the UCA Accreditation Department by email at email@example.com.
To avoid a lapse in an organization’s accreditation status a re-survey will be required once every three years. UCA will notify accredited organizations six months prior to accreditation expiration that reapplication is necessary. Organizations choosing to become reaccredited must submit a renewal application and will receive advance notice of their re-survey date(s).
- Six months prior to expiration: Renewal application reminder will be sent out no later than 6 months prior to the expiration.
- Three months prior to expiration: A second reminder notice will be sent that applicants must apply and submit payment prior to their expiration date, or their accreditation will expire.
- One month prior to expiration: Notification sent stating that the organization’s accreditation status will expire, and that organization should apply online via UCA’s CertBank application. At this point, the applicant may not be able to renew prior to expiration as surveyor availability may be limited.
- One month after expiration the organization will receive official notification that the organization’s accreditation status has expired.
In between accreditation and reaccreditation processes, organizations are welcome to contact UCA staff regarding all accreditation-related questions at firstname.lastname@example.org. Additionally, standard updates will be made available via the UCA website page for Accredited Centers.
What happens if we allow our accreditation status to lapse and then decide to re-apply?
Lapses in an organizations Accreditation Status: Should an organization choose not to apply for re-accreditation and their UCA Accreditation status lapses, but the organization elects to re-apply within one year of the expiration date, it will still be considered a renewing organization. After a year past its expiration date, the organization’s application and survey will be considered first-time / initial application and a history of compliance will no longer be expected. A new application will need to be submitted online along with the application fee.
Renewals: A re-survey will be scheduled and at the time of the survey. The UCA surveyor will be looking for a history of compliance since the previous survey. The accreditation date will be backdated to the original expiration date therefore demonstrating no lapse