UCA

URGENT CARE ASSOCIATION

Frequently Asked Questions

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). 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. Contact us at quality@ucaoa.org for an Early Accreditation application.

How do I obtain the UCA Accreditation Standards and Preparation Manual?
This manual consists of the requirements, Standards and Expectations, of the accreditation program. The UCA Accreditation Standards and Preparation Manual is an e-manual and is available for sale prior to applying. Upon receipt of a completed and paid application, the organization will receive a copy of the manual via email. Should an organization choose to purchase the 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 the 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 and an Expectation?
Both a Standard and an Expectation are a requirement that must be demonstrated to prove compliance. Expectations provide greater detail of the standard.

What happens during a survey?

  • The UCA survey experience is both facilitative and collaborative.
  • 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. Once the organization can meet the Certification Criteria, the organization will need to submit a new application with application fee.
  • On the renewal survey, it is necessary to demonstrate a history of compliance within the organization for Standards and Expectations during the previous three years. Therefore, the organization should maintain records of compliance for the full accreditation period.
  • Once the survey is scheduled, organizations receive the current Accreditation Survey Welcome Packet with additional information on the survey process and requirements.

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
  • Practice Administrators
  • Health Care Professionals
  • Recently retired senior leadership from Urgent Care organizations
  • Physicians and Advanced Practice Practitioners (APPs)

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 survey?
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 in 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 a mock survey to create comfort with the survey process and to familiarize staff with the survey expectation.
  • Review the Certification Criteria, Standards Manual, and Survey Welcome Packet and Checklists to ensure that you meet the criteria established.
  • 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 onsite at the organization. Also, designate a staff person to facilitate all interactions with the surveyor who is adept at accessing records and other important documents.
  • 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 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 for UCA administrative review. UCA then begins preparing your Survey Findings Report. This report identifies only those Standards/Expectations 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.

The organization will receive a copy of your report via email to the Key Contact on file. It will be accompanied by instructions for how to prepare the response in electronic format. In addition, the email will outline due dates, organizations have sixty (60) days to complete the any action required items.

What happens if we cancel?
An organization that voluntarily withdraws from the accreditation process at any time will forfeit its full application fee. Forfeited funds may not be applied to any other UCA events, products, membership, education, or materials.

What are the levels of accreditation awarded?
Accreditation plus Certification are awarded as follows:

Accreditation or Reaccreditation: Accreditation or reaccreditation is awarded 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 there are questions about an organization's implementation of/continuing performance with a Standard that may require additional documentation/information for approval, UCA may place the organization on pending status to request this documentation. Full accreditation is not granted until the organization submits the required documentation and UCA finds it now meets the standard.

Provisional: accreditation is granted to an organization with the stipulation that the organization must submit additional documentation of completed compliance or undergo additional survey within a designated time frame. If the organization does not comply, its accreditation designation is revoked. Additionally, provisional status may be awarded if a virtual survey has been successfully completed but an onsite visit is pending.

Right to Resurvey: UCA 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: UCA 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 request for additional documentation/information within the designated time frame.

An organization has the right to appeal any Accreditation 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 accreditation.
  • Notification letter stating that your organization has been accredited and certified with your effective and expiration dates, and any additional commendations awarded.
  • Promotional tools to help convey your monumental achievement to your staff, community, and other stakeholders. Tools will include a window cling per center, sample public statements, and other suggested actions to take. Additionally, UCA will promote your successful dual accreditation/certification distinction on its website.
  • Certificate 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 center to be accredited upon execution and submission of a written attestation that the center operates under the same standards and policies/procedures as the surveyed accredited sites. Accreditation 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 new location fee will be assessed per center added by attestation.

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 follow UCA Standards/Expectations and policies/procedures as the surveyed accredited sites within 120 days of the acquisition or merger. Accreditation certificates will be available for the newly acquired or merged centers once the attestation statement is received and the invoice for new sites is paid. The accreditation status for the new center(s) will expire commensurate 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 findings and allow UCA 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 quality@ucaoa.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.

To avoid a lapse in an organization’s accreditation status a re-survey will be required once every three years. Organizations choosing to become reaccredited must submit a renewal application and pay the reaccreditation fee eight months prior to the expiration. Three months prior to expiration, if the organization has not applied for renewal, paid the reaccreditation fee, and scheduled their survey, the applicant may not be able to renew prior to expiration as surveyor availability may be limited.

In between accreditation and reaccreditation processes, organizations are welcome to contact UCA staff regarding all accreditation-related questions at quality@ucaoa.org.

What happens if we allow our accreditation status to lapse and then decide to re-apply?
Should an organization choose to re-apply for accreditation after their UCA Accreditation status lapses, the organization’s application and survey will be considered an initial application. Organizations cannot obtain accreditation for six months past their lapsed accreditation date. Organizations should avoid lapsing, as a repeating cycle of lapse/initial application is not allowed.

Ready to apply?
Contact us at quality@ucaoa.org for an application!

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