Our Step-by-Step Process to Accreditation
Step 1: Self-assessment of the organizations services to compile standards.
We meet with the owners and department heads to determine all standards that apply to the organization. This process allows us to gain a detailed view of what types of services and treatment is provided. We then consolidate the standards that apply to the organization.
Step 2: Review of all policies, procedures and medical records for deficiencies.
We review all policies and procedures to determine what standards the organization is currently in compliance with. We gain access to the medical record (either paper or electronic) and determine any deficiencies. We work hand and hand with electronic medical record system employees to ensure the implementation of standards into a medical record. We also review all human resource files for deficiencies and assist in creating documentation needed for the organization to become compliant.
Step 3: Onsite inspection of all organizations properties for safety compliance
We complete a thorough inspection of each building mandated for review by the Joint Commission. This inspection includes hazardous threats, fire safety equipment, building structure, etc.
Step 4: Assisting with The Joint Commission application process.
We assist and oversee in the application process to ensure accuracy and ease.
Step 5: Meeting with the organizations leaders to modify positions and establish structure.
We work with leaders of the organization to create a structured work environment. We want to ensure that each staff member is overseeing the appropriate processes within the organization. Providing structure in job duties for each staff member helps with creating and maintaining compliance.
Step 6: Meeting with each department staff members to modify and/or create policies and procedures.
We modify or create policies and procedures customized to your organization and the standards of the Joint Commission. Each organization is unique in the services provided, we work with each member to ensure that the organizations goals are shown through their practices.
Step 7: Implementation of safety standards and overseeing installation of necessary safety equipment and procedures in properties.
We meet with building contractors, property managers, etc. to provide the exact locations and oversee the installation process of all safety equipment.
Step 8: Training staff leaders on new policies and procedures..
We train each staff member on all new policies and procedures created for the organization. We train staff on all areas of standards that require logging of information such as disposal of medications, fire drills, data collection, etc.
Step 9: Providing mock tracer questions to staff members.
We provide mock tracer questions to department leaders and review these with staff members approximately 3 – 4 weeks prior to survey.
Step 10: Assistance with completion of any corrective action plans.
We assist with the completion of any corrective action plans. We collaborate with department leaders and owners in the necessary changes needed for correction and create an implementation plan.
